Student Health Assessment

Student Health Assessment Form

Complete this form to provide your health information for St. Anthony Regional Hospital and Nursing Home.
Student Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Educational Institute Name (Or Other)
Latex Allergy
Immunization History
You may upload a copy of your immunization or health records here if able.

Cancelof
COVID-19 Vaccination
Have you received a COVID-19 vaccination?
If Yes, please provide the information about your particular COVID-19 vaccine. If no, skip to the next section.
Moderna First Dose Date

MonthDayYear
Date
Moderna Second Dose Date

MonthDayYear
Date
Moderna Boost Dose Date

MonthDayYear
Date
Pfizer First Dose Date

MonthDayYear
Date
Pfizer Second Dose Date

MonthDayYear
Date
Pfizer Boost Dose Date

MonthDayYear
Date
Johnson &Johnson Date

MonthDayYear
Date
Johnson &Johnson Boost Dose Date

MonthDayYear
Date
Influenza Vaccination
Date of Last Influenza Vaccine

MonthDayYear
Date
Measles, Mumps, Rubella (*MMR) Vaccination
A total of two MMR's or a blood test (titer) showing positive immunity is required.
Measles/Mumps/Rubella (MMR) Immunization Date

MonthDayYear
Date
Measles/Mumps/Rubella (MMR) Booster Date

MonthDayYear
Date
Measles/Mumps/Rubella (MMR) Date of Positive Titer

MonthDayYear
Date
Hepatitis B Vaccination
Hepatitis B vaccinations are not a requirement, but recommended for anyone at risk for exposure to blood and/or blood products. A declination must be completed if applicable.
Date of 1st Hepatitis B Injection

MonthDayYear
Date
Date of 2nd Hepatitis B Injection

MonthDayYear
Date
Date of 3rd Hepatitis B Injection

MonthDayYear
Date
Date of Hepatitis B Titer

MonthDayYear
Date
Varicella (Chicken Pox) Vaccination
Two Varicella vaccinations OR a positive titer will be accepted
Varicella Vaccination Date

MonthDayYear
Date
2nd Varicella Vaccination Date

MonthDayYear
Date
Varicella Date of Positive Titer

MonthDayYear
Date
Tuberculosis (TB) Screening
Please provide official TB skin test results. Students consistently scheduled for 5 or more hours per week are required to have 2-step TB skin test. At least one step (skin test) must be completed within the 12 months prior to working at St. Anthony. If needed, students may obtain a TB skin test from the St. Anthony Employee Health Nurse for a fee of $25.
TB Skin Test #1 Date

MonthDayYear
Date
TB Test #1 Lot Number if known
TB Test Results #1 in millimeters
TB Skin Test #2 Date

MonthDayYear
Date
TB Test #2 Lot Number if known
TB Test Results #2 in millimeters
IGRA (Quantiferon Gold or T-spot) Results
IGRA (Quantiferon Gold or T-spot) Date

MonthDayYear
Date
Tuberculosis Symptom Screening
List each hospital(S) where you have worked within the last 12 months. If none, state NONE.
Have you had any of the signs/symptoms in the last year? (All questions must be answered.)
For each question, place a checkmark in the box if the answer is Yes.
If you answered Yes to any of these questions, please explain.
Past Training Received
I have received training on Blood Borne Pathogen Prevention
I have received training on Mandatory Child and Adult Abuse Reporting
I certify that all of the statements provided here are true and correct to the best of my knowledge.
Should be Empty:

Student Health Assessment Form

Immunization History

COVID-19 Vaccination

Influenza Vaccination

Measles, Mumps, Rubella (*MMR) Vaccination

Hepatitis B Vaccination

Varicella (Chicken Pox) Vaccination

Tuberculosis (TB) Screening

Tuberculosis Symptom Screening

Past Training Received