• Annual Self-Assessment

  • In order to comply with New York State Department of Health Regulation 766.11 an annual, or more frequent if necessary, health status assessment to assure that all personnel are free from any health impairment that is of potential risk to the patient, family or to employees or that may interfere with the performance of duties. The assessment shall be of sufficient scope that no person shall assume his/her duties unless he/she is free from a health impairment which is of potential risk to the patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior.

  • How would you rate your general state of health?*
  • Have you gained or lost more than 10 pounds in the past year?*
  • Are you on a special or restricted diet?*
  • Date of last physical examination by medical professional:*
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  • Have there been any changes in your health since the date of your last physical or annual self-health assessment that would prohibit you from performing the essential functions of your job?*
  • Is there anything in your current health status that puts you or the consumer at risk?*
  • Are you addicted to, or habitually use, depressants, stimulants, narcotics, alcohol, or other drugs or substances that could alter your behavior?*

  • I hereby certify that the above statements are true and answered to the best of my knowledge and ability. I hereby certify that I am capable of performing my job duties.

  • Date*
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  • TB Assessment

  • Date of Birth*
     - -
  • Hire Date*
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  • Last TB (Tuberculin) Skin Test Administered Date
     - -
  • Date Read
     - -

  • Have you experienced any of the following symptoms in the past year?

  • A productive cough for more than 3 weeks?*
  • Hemoptysis (coughing up blood)?*
  • Unexplained weight loss?*
  • Fever, chills, or night sweats for no known reason?*
  • Persistent shortness of breath?*
  • Unexplained fatigue?*
  • Chest pain?*
  • Have you had contact with anyone with active tuberculosis disease in the past year?*
  • Do you have a medical condition, or are you taking medications which suppress your immune system?*

  • If the answer is YES to any of the above questions, agency requires that a health care provider complete a tuberculosis skin test (TST) before returning to work. Results of a tuberculin skin test (PPD) or blood test such as Quantiferon Gold or a T-Spot must be provided, unless a previous positive test has been documented. A normal chest x-ray performed is required for a positive PPD blood test. A written medical interpretation of the x-ray (in English) must be included.

  • I declare that my answers and statements are correctly recorded, complete, and true to the best of my knowledge.

  • Today's Date*
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