Health Screening Form

8/13/2019 Health Screening Form

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Research Institute for Tropical Medicine

Health Screening Program

Name: ____________________________

Date of Birth: ______________________

Position: __________________________

Please check the box that corr esponds to your cur rent health status

Tuberculosis Screen Form

YES NO

Do you have any history of TB exposure?Do you have any history to positive TB test?

Do you have any history to TB treatment?

Have you ever had Chest X-ray for TB detection?

Do you have allergy in TB test solution?

If your answer is mostly yes answer the table below with the physician in the nursing

service

(Any positive symptoms warrant a mask and CXR)

YES NO

Persistent Fever?

Persistent Coughing? (more than 6 weeks)

Night Sweats?

Coughing up blood?

Unexplained Weight loss?


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Hepatitis B Screen Form

YES NO

Have you missed the required series of Hepatitis B Immunization?

Can attached documentation slip of Hepatitis B Immunization

I dont have the record but know the dates of my Hepatitis BImmunization

____________, ____________, _____________

I dont have the knowledge if I completed my Hepatitis B immunization and

request the institution to provide me the Hepatitis B Immunization

I f the vaccine is given 10 years before; a Hepatiti s B titer is needed contact clin ic physician i s

needed.

Measles, Mumps, Rubella

I already have developed the following diseases: Measles, Mumps, and Rubella:

(Can attached documentation f rom physician of confi rmed case of Measles, Mumps, and

Rubella)

Measles Mumps Rubella

YES NO

Have you missed the MMR vaccination?

Can attached documentation slip of MMR vaccinationI dont have knowledge of any vaccination of MMR, I request to provide methe MMR vaccination


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Varicella (Chicken Pox)

I already had a confirmed case of Varicella?

(Can attached documentation sli p fr om physician of confi rmed case of Vari cell a)

YES NO

Have you failed to receive Varicella immunization 2 shot series?

Can attached documentation slip of Varicella Immunization I dont have the records but remembered the dates of my 2 shot

varicella immunization

__________, ____________

I dont have knowledge of my Varicella immunity, I request the institution to

provide me the Varicella vaccination

Pertussis (Whooping Cough)

YES NO

Have you missed to receive DPwT Immunization?

Can attached documentation slip of DPwT immunizationI dont have knowledge of my Pertussis immunity, I request the institution to

provide me the pertussis immunization

Diphtheria

YES NO

Have you missed to receive DPaT Immunization?

Can attached documentation slip of DPaT immunizationI dont have knowledge of my Diphtheria immunity, I request the institution

to provide me the diphtheria immunization


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Tetanus

YES NO

Have you missed to receive DPaT Immunization or DT immunization

Can attached documentation slip of DPaT or DT immunization

I dont have knowledge of my Tetanus immunity, I request the institution to

provide me the tetanus immunization

Influenza Immunization

YES NO

Have you failed to receive annual Influenza immunization? If no until when is the validity of the taken immunization? I dont have Influenza immunization, I request the institution toprovide me the Influenza immunization

Rabies Vaccination

I already have receive pre-exposure and post-exposure anti-rabies vaccination

(Can attached documentation form of conf irmed administration of anti -rabies

vaccination)

YES NO

Have you failed to receive anti-rabies vaccination? I dont have tetanus vaccination, I request the institution to provide

me the tetanus vaccination.

(The fol lowing vaccination can be completed with then two months of exposure or

immediately upon admission of thi s disease)

Pneumococcal Disease

YES NO

Have you failed to receive pneumococcal polysaccharide vaccination I dont have a pneumococcal polysaccharide vaccination; I request the

institution to provide me the vaccination.


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Meningococcal Disease

YES NO

Have you failed to receive meningococcal vaccination? I dont have a meningococcal vaccination; I request the institution to

provide me the vaccination.

Typhoid Vaccination

YES NO

Have you failed to receive a typhoid vaccination? I dont have a typhoid vaccination; I request the institution to provide

me the vaccination.

Hepatitis A

YES NO

Have you failed to receive a Hepatitis A vaccination? I dont have hepatitis A; I request the institution to provide me the

vaccination.

Signature:_____________________________

Clinician Signature:____________________

If categorize at B, you are permitted to have an exposure to all areas in R.I.T.M

If categorize at A, you are limited to only areas you are protected, until you completed

enhancement program.

CATEGORIZATION A B


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CATEGORIZATION SHEET

Categorize the new nurse under A if he/she has at least one YES under the HealthScreening Form

Categorize the new nurse under B if he/she has at least one NO under the Health

Screening Form and if he/she has passed a documentation slip of having that king of

disease (MMR, Vari cell a, Rabies)

Categorization B limitation

Dont expose the new nurse to areas wherein he/she have no protection yet

Dog Bite Facil itySouth Station (For Var icell a and Inf luenza)

Health Screening Form

Documents

Transcript of Health Screening Form