Employee Health Assessment

Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Latex Allergy?
If Yes, please describe latex allergy symptoms.
Immunization History
Please upload a copy of all past immunizations, including all those received as an infant or child and / or you may continue to sections below.

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

MonthDayYear
Date
Moderna Second Dose Date

MonthDayYear
Date
Pfizer First Dose Date

MonthDayYear
Date
Pfizer Second Dose Date

MonthDayYear
Date
Johnson &Johnson Date

MonthDayYear
Date
Influenza Vaccine
Have you received a flu vaccination?
Date of Last Influenza Vaccine

MonthDayYear
Date
Measles, Mumps, Rubella (*MMR)
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
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)
Two Varicella vaccinations OR a positive titer will be accepted.
Chicken Pox/Varicella Vaccination Date

MonthDayYear
Date
2nd Chicken Pox/Varicella Vaccination Date

MonthDayYear
Date
Chicken Pox/Varicella Date of Positive Titer

MonthDayYear
Date
Tuberculosis (TB) Screening
Please provide official TB skin test results. Employees 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, you 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 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 below, 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 Abuse Reporting
If yes, please upload or provide copies of Mandatory Child Abuse Reporter training certificate.

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I have received training on Mandatory Adult Abuse Reporting
If yes, please upload or provide copies of Mandatory Adult Abuse Reporter training certificate.

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I have American Heart Association Based Life Support (BLS) Certification
If yes, please enter AHA Basic Life Support (BLS) certification expiration date:

MonthDayYear
Date
Please upload or provide copies of AHA Basic Life Support (BLS) certification card

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I have Advanced Cardiac Life Support (ACLS) Certification
If yes, please enter Advanced Cardiac Life Support (ACLS) certification expiration date:

MonthDayYear
Date
Please upload or provide copies of Advanced List Support (ACLS) certification card

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I have Advanced Pediatric Advanced Life Support (PALS) Certification
If yes, please enter Pediatric Advanced Life Support (PALS) certification expiration date:

MonthDayYear
Date
Please upload or provide copies of Pediatric Advanced Life Support (PALS) certification card

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By signing your full name, you attest to the validation of your application.
Should be Empty:

Immunization History

Covid-19 Vaccination

Influenza Vaccine

Measles, Mumps, Rubella (*MMR)

Hepatitis B

Varicella (Chicken Pox)

Tuberculosis (TB) Screening

Tuberculosis Screening

Past Training Received