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CHILD, YOUTH, AND SCHOOL SERVICES EMPLOYEE HEALTH ASSESSMENT/SCREENING

(AE Reg 608-10-1)

Data required by the Privacy Act of 1974

Authority: 10 USC 3013.

Purpose: (1) Verify employee health and status of immunizations; (2) Note special program considerations.

Routine uses: In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act, these records and information may specifically be disclosed outside DOD as a routine use pursuant to 5 USC 552a(b)(3) as follows: information from this system may be disclosed to civilian health and welfare departments/agencies in emergency situations. The "Blanket Routine Uses" set forth at the beginning of the Army Compilation of Systems of Records Notices also apply.

Disclosure: Voluntary, but if information is not provided, applications for prospective employment will not be processed and current employees may be evaluated regarding their suitability and qualification for continued employment.

Initial Health Assessment

Employee name (last, first, MI)

Assessment completed by (Full name of healthcare professional completing initial assessment, position, work address, and telephone number.)

Employee—

Yes

No

a. Is free of evidence of tuberculosis according to risk assessment as prescribed in MEDCOM Reg 40-64, using

    MEDCOM Form 829. A TST was not performed

b. Is assessed to be free of other communicable diseases according to medical history and available medical records.

c. Meets all immunization requirements according to AE Reg 608-10-1, table B-1.

d. Meets all additional health requirements (able to walk, bend, stoop, stand, and lift 40 pounds).

Comments (Identify any physical or other limitations that may affect the ability to perform assigned duties.)

Healthcare professional

Name

Date (YYYYMMDD)

Signature

The following clearances are valid for 1 year from the date of screening.

Annual Health Review (1st Year)

1. The tuberculosis risk assessment as prescribed in MEDCOM Reg 40-64, using MEDCOM Form 829, found no evidence of tuberculosis.

    A TST was not performed.

2. Employee states he or she is free from other communicable diseases.

3. Immunization requirements detailed in AE Reg 608-10-1, table B-1, are current.

4. Able to walk, stand, stoop, bend, and lift 40 pounds.

Healthcare professional

Name and title

Date (YYYYMMDD)

Signature

Employee

Name

Date (YYYYMMDD)

Signature

Annual Health Review (2d Year)

1. The tuberculosis risk assessment as prescribed in MEDCOM Reg 40-64, using MEDCOM Form 829, found no evidence of tuberculosis.

    A TST was not performed.

2. Employee states he or she is free from other communicable diseases.

3. Immunization requirements detailed in AE Reg 608-10-1, table B-1, are current.

4. Able to walk, stand, stoop, bend, and lift 40 pounds.

Healthcare professional

Name and title

Date (YYYYMMDD)

Signature

Employee

Name

Date (YYYYMMDD)

Signature

Annual Health Review (3d Year)

1. The tuberculosis risk assessment as prescribed in MEDCOM Reg 40-64, using MEDCOM Form 829, found no evidence of tuberculosis.

    A TST was not performed.

2. Employee states he or she is free from other communicable diseases.

3. Immunization requirements detailed in AE Reg 608-10-1, table B-1, are current.

4. Able to walk, stand, stoop, bend, and lift 40 pounds.

Healthcare professional

Name and title

Date (YYYYMMDD)

Signature

Employee

Name

Date (YYYYMMDD)

Signature

Annual Health Review (4th Year)

1. The tuberculosis risk assessment as prescribed in MEDCOM Reg 40-64, using MEDCOM Form 829, found no evidence of tuberculosis.

    A TST was not performed.

2. Employee states he or she is free from other communicable diseases.

3. Immunization requirements detailed in AE Reg 608-10-1, table B-1, are current.

4. Able to walk, stand, stoop, bend, and lift 40 pounds.

Healthcare professional

Name and title

Date (YYYYMMDD)

Signature

Employee

Name

Date (YYYYMMDD)

Signature

9.0.0.2.20101008.1.734229

AE Form 608-10-1F, June 2014 (LCD Vers. 01.00)

Child, Youth, and School Services Employee Health Assessment/Screening

Child, Youth, and School Services Branch, Office of the Assistant Chief of Staff, G9, IMCOM-Europe (IMEU-MWR-C), Unit 29064, APO AE 09136-9064 (DSN 496-5620)

JavaScript_Note_FIELD: Click to print this form.: Click to send form (PDF file) by e-mail.: Click to reset/clear form. Digitally signed forms cannot be cleared.: Click to open the prescribing directive for this form.: Page_GoTo_FIELD: GotopageClick to go to page 1.: Click to go to page 2.: Form_NumberDate_FIELD: AE FORM 608-10-1F, JUN 14Form_Version_FIELD: LCD Vers. 01.00CurrentPage_FIELD: PageCount_FIELD: Enter name of employee (Last, first, middle initial (MI)).: Enter full name of healthcare professional completing initial assessment, position, work address, and telephone number.: Check if employee is free of evidence of tuberculosis according to the risk assessment in MEDCOM Reg 40-64 (unchecked by default).: 0Check if employee is not free of evidence of tuberculosis according to the risk assessment in MEDCOM Reg 40-64 (unchecked by default).: 0Check if employee is assessed to be free of other communicable diseases (unchecked by default).: 0Check if employee is not assessed to be free of other communicable diseases (unchecked by default).: 0Check if employee meets all immunization requirements according to AE Reg 608-10-1, table B-1 (unchecked by default).: 0Check if employee does not meet all immunization requirements according to AE Reg 608-10-1, table B-1 (unchecked by default).: 0CCheck if employee meets all additional health requirements (able to walk, bend, stoop, stand, and lift 40 pounds) (unchecked by default).: 0Check if employee does not meet all additional health requirements (able to walk, bend, stoop, stand, and lift 40 pounds) (unchecked by default).: 0Comments: Identify any physical or other limitations that may affect ability to perform assigned duties.: Enter name of healthcare professional.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Check if the tuberculosis risk assessment (MEDCOM Reg 40-64, using MEDCOM Form 829) found no evidence of tuberculosis (unchecked by default).: 0Check if employee states that he or she is free from other communicable diseases (unchecked by default).: 0Check if immunization requirements detailed in AE Reg 608-10-1, table B-1, are current (unchecked by default).: 0Check if employee is able to walk, stand, stoop, bend, and lift 40 pounds (unchecked by default).: 0Enter name and title of healthcare professional.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Enter name of employee.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Check if the tuberculosis risk assessment (MEDCOM Reg 40-64, using MEDCOM Form 829) found no evidence of tuberculosis (unchecked by default).: 0Check if employee states that he or she is free from other communicable diseases (unchecked by default).: 0Check if immunization requirements detailed in AE Reg 608-10-1, table B-1, are current (unchecked by default).: 0Check if employee is able to walk, stand, stoop, bend, and lift 40 pounds (unchecked by default).: 0Enter name and title of healthcare professional.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Enter name of employee.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Check if the tuberculosis risk assessment (MEDCOM Reg 40-64, using MEDCOM Form 829) found no evidence of tuberculosis (unchecked by default).: 0Check if employee states that he or she is free from other communicable diseases (unchecked by default).: 0Check if immunization requirements detailed in AE Reg 608-10-1, table B-1, are current (unchecked by default).: 0Check if employee is able to walk, stand, stoop, bend, and lift 40 pounds (unchecked by default).: 0Enter name and title of healthcare professional.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Enter name of employee.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Check if the tuberculosis risk assessment (MEDCOM Reg 40-64, using MEDCOM Form 829) found no evidence of tuberculosis (unchecked by default).: 0Check if employee states that he or she is free from other communicable diseases (unchecked by default).: 0Check if immunization requirements detailed in AE Reg 608-10-1, table B-1, are current (unchecked by default).: 0Check if employee is able to walk, stand, stoop, bend, and lift 40 pounds (unchecked by default).: 0Enter name and title of healthcare professional.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: Enter name of employee.: Select from calendar or enter date of signature (YYYYMMDD).: Enter your common access card (CAC) and click to digitally sign this form.: