pre-employment health packet · pre-employment health packet. ... official employee health use only...

BHSF 6321 Rev. 11/4/16

PRE-EMPLOYMENTHEALTH PACKET

BHSF #6155 Rev. 1/13

PRE-EMPLOYMENT INFORMATION SHEET

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SOCIAL SECURITY #: _____ - _____ - ________ Date of Birth: _____ / _____ / 19_______ Employee ID#: ____________

NAME: ______________________________________________________________________________________________ (Last) (First) (Middle)

ADDRESS: ___________________________________________________________________________________________ (Street or Mailing) (City / ST) (Zip Code)

Home Phone: (_____) _____ - _________ Cell: (_____) _____ - _________ Email: _______________________________

Date of Hire #: ______ - ______ - ________ Job Title: ________________________ Department: __________________

ALLERGIES: __________________________________________________________ LATEX allergy : G Yes G No

Current MEDs: ________________________________________________________________________________________

Drug Screen Date: _________________ G Neg G Pos

DATE of Physical: _______ / ________ / ____________

Location: Please G (1) BoxG Baptist G South MIami G Doctors G Homestead G West Kendall G Mariners G BOS / BHE G Corporate

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DO NOT WRITE BELOW THIS SECTION - OFFICIAL EMPLOYEE HEALTH USE ONLY

Examiner Signature:_____________________________________________

QUANTIFERON DATE / / q Neg q Pos

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2BHSF #6148 Rev. 2/22/16

EMPLOYEE HEALTH SERVICES

VITALS AND VISION SHEET

Name: ________________________________________________________________________ Date: ________________

DOB: ___________________ G Male G Female Height: _______’ _______” Weight: __________ lbs

DO NOT WRITE BELOW THIS SECTION - FOR EMPLOYEE HEALTH OFFICE USE ONLY

BP: _______________________ Pulse: _____________________ Temperature: _________________

Date: _____________________ Recheck BP: _______________ Pulse: ______________________

Vision: Right Eye: ________ / ________ Left Eye: ________ / ________ Both Eyes: ________ / ________

With Contacts: ______________________________ With Glasses: ______________________________

COLOR BLIND TESTING - Ishihara Test Edition Date: ____________ PLATE No. NUMBER READ RESULTS / comments

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Examining Practitioner: _______________________________________________ G PASS G FAIL

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HEALTH HISTORY & SCREENING - STATEMENT

Name: __________________________________________________ Date: ___________________________________

DOB: __________________________________________ Last 4 Digits of Social Security #: XXX - XX - ___________

WELCOME TO BAPTIST HEALTH.

Employee Health Services is here to provide health care for you. We are available for consultation, medical referrals, care and treatment.

•Pleasetakeyourtimeandcarefullyreadthefollowinghealthhistoryform.

•Answerallquestions.Weareavailabletoassistyouifnecessary.

Please initial at the end of each statement: 1) Youranswerstothefollowingquestionsaretoassistinplacingyouinajobsafetoyouand

to others. _______ (Initials)

2) Iunderstandsuchinformationpertinenttomyjobdescriptionmaybemadeavailabletomy

supervisor. ________ (Initials)

3) I authorize Employee Health Services to perform any physical and/or laboratory examination,

whichisnecessarytoverifytheabsenceofcommunicablediseaseoranycondition,which

might impair the performance of my duties as an employee of BAPTIST HEALTH.

________ (Initials)

4) I understand that any offer of employment is contingent upon satisfactorily completing the

health assessment. _______ (Initials)

5) IherebyaffirmthattheinformationprovidedinthisHealthHistory&Screeningistrueand

correct. _____ (Initials)

Examiner Initials: _____________

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HEALTH HISTORY & SCREENINGName: __________________________________________________ Date: ___________________________________

DOB: __________________________________________ Last 4 Digits of Social Security #: XXX - XX - ___________

HISTORY1. Haveyoueverhadabackconditionorinjury?G No G YES Year: ___________________________________________

Listconditionorinjury: ________________________________________________________________________________________

Describe incidents: __________________________________________________________________________________________

__________________________________________________________________________________________________________

Didyouconsultwithaphysicianregardingyourbackproblem?G No G YES

Physician’s name: ____________________________________________ Specialty: ___________________________________

Describe type of treatment: ____________________________________________________________________________________

DidyouhaveanyX-RAY,MRI,and/orCT? _______________________________________________________________________

Previousbacksurgery? _______________________________________________________________________________________

2. Haveyoueverhadaneckconditionorinjury?G No G YES Year: ___________________________________________

Listconditionorinjury: ________________________________________________________________________________________

Describe incidents: __________________________________________________________________________________________

__________________________________________________________________________________________________________

Didyouconsultwithaphysicianregardingyourneckproblem?G No G YES Year: ______________________________

Physician’s name: ____________________________________________ Specialty: ___________________________________

Describe type of treatment: ____________________________________________________________________________________

DidyouhaveanyX-RAY,MRI,and/orCT? _______________________________________________________________________

Previousnecksurgery? _______________________________________________________________________________________

3. Doyoustillsuffereffectsfromtheback/neckproblemdescribedabove?G No G YES

4. If so, check symptoms and severity (1 - 10) you continue to experience at time : 1 = MILD - 10 = SEVERE

G _____ Weakness G _____ Tingling G _____ Dizziness G _____ Numbness

G _____ Headache G _____ Soreness after lifting G_____Painwithlifting G_____PainwithCoughing

G_____Tirednessafterwork

5. Doyoutakeanymedicationsforyourback/neckcondition?G No G YES

List of Medications: ___________________________________________ Howoftentaken: ______________________________

6. DoyouhavetroubleperformingtheActivitiesofDailyLiving?G No G YES

Describe limitations: _________________________________________________________________________________________

7. Haveyoueverbeenunabletoworkbecauseofconditionorinjury?G No G YES

Examiner Comment: _____________________________________________________________________________________________

Examiner Initials: ________________ Employee/Applicant Initials: ________________

Page 2 of 6 • BHSF #6151 Rev. 2/22/16

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HEALTH HISTORY & SCREENING (CONTINUED)

Yes NoDO YOU HAVE OR HAD THE

FOLLOWING:RESPIRATORY CONDITION(S):

Applicant’s Comment Examiner’s Comment

1. Asthma

2. Emphysema

3. Bronchitis

4. Smoker?/HowLong?

5. Tuberculosis

6. Other

CARDAC CONDITION(S):

1. High Blood Pressure

2. Heart Condition

3. Congestive Heart Failure (CHF)

4. Open Heart Surgery

5. Heart Attack

6. Chest Pain

7. Other

NEURO/MUSCULAR, SKELETAL & JOINT CONDITION(S)

1. Hand/WristInjury;CarpalTunnel

2. Shoulder/ElbowInjury

3. Back Sprain

4. Back-Herniated Intervertebral Disc

5. Back-Surgical Procedure

6. Broken Bones

7. KneeInjury

8. AnkleInjury

9. Leginjury

10. Hip Disorder

11. Foot Problem

12. Amputation of Foot/Leg/Arm/Hand

13. Neckinjuryorpain

14. Orthopedic surgery

15. Poliomyelitis – Residual Disability

16. Arthritis/ Gout

17. Chronic Osteoarthritis

18. Other

COMMENTS: Please include any testing (x-ray, CT, MRI, etc.), Physician name and address, tel. # and fax #

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________


Name: ________________________________________________

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Yes NoDO YOU HAVE OR HAD THE

FOLLOWING:ABDOMINAL CONDITION(S):

Applicant’s Comment Examiner’s Comment

1. Stomach and/or Intestinal disorder

2. IrritableBowelSyndrome

3. Colitis

4. Crohns

5. Gall Bladder

6. Ulcer

7. Kidney Disease

8. Hernia

9. Hepatitis

10. Liver Disease

11. Other

MEDICAL CONDITION(S):

1. Diabetes

2. Epilepsy / Seizure Disorder

3. Headaches / Migraines

4. HeadInjury

5. Vascular Disorder

6. Stroke (CVA)

7. Thrombophlebitis (Blood clot)

8. Anemia

9. Circulatory problems

10. Bleeding disorder

11. Cancer

12. Immunosuppressive condition

OTHER:

1. Deafness–total or partial hearing loss

2. Ear Condition

3. Eye Condition

4. Total or partial loss of sight

5. ColorBlind(ColorDeficiency)

PAST HISTORY:

1.

Are you currently or have you ever been under the supervision of IPN, PRN, or theDepartmentofHealth?Ifyes,pleaseexplain circumstances, including dates.

WOMEN ONLY:

1.Areyoupregnant?IfYES;Estimated date due: ______________

Name: ________________________________________________


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Name: ________________________________________________

LIST ALL: Examiner Comments

Surgical Procedures: ____________________________________________________ _____________________________________

__________________________________________________________________ _____________________________________

Car Accident: _________________________________________________________ _____________________________________

__________________________________________________________________ _____________________________________

Other Accidents: ______________________________________________________ _____________________________________

__________________________________________________________________ _____________________________________

AnyotherIllnessorConditionnotlisted? ____________________________________________________________________________

Please Note: Baptist Health South Florida requires copies of any workman’s compensation/auto and any other accident claim, medical records and work releases.

HaveyoueverhadanyWorkers’Compensationinjuries/orclaims? G No G YES (describebelow)

Date Injury Company State

DidyoufilealawsuitagainstyouremployerinanyWorkers’Compensationcase? G No G YES

Willanyconditionlimityouinanywayintheperformanceofyourspecificjobdescription? G No G YES

EXPLAIN

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________


Please Note: The information you provide herein will be independently verified through our background check process. If you omit information or provide misleading or incorrect information you may be subject to corrective action, including the revocation of this job offer or termination.

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ADA ACCOMMODATIONS:

1) Ihavereceived,read,andunderstandmyjobdescriptionaswellastheessentialfunctionsofthejob;IfeelIcan perform these functions. G No G YES

2) Willanypersonalphysical/emotionalconditionlimityouinanywayintheperformanceofyourspecificjob description? G No G YES (describebelow)

____________________________________________________________________________________________

____________________________________________________________________________________________

3)Haveyoueverbeenunabletoworkbecauseofanillness,injury,orcondition? G NO G YES(describebelow)

____________________________________________________________________________________________

____________________________________________________________________________________________

4)Doyouneedspecialaccommodation(s)toperformtheessentialfunctionsofthisjob? G NO G YES

COMMENTS: _______________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

GMandatoryInfluenzaReviewed HealthProviderInitials:_________

I CERTIFY THAT THIS HEALTH HISTORY IS TRUE AND COMPLETE AND THAT I DO NOT HAVE ANY ILLNESS, INJURY OR CHRONIC DISEASE OTHER THAN STATED WITHIN THIS DOCUMENT. I ACKNOWLEDGE THAT THE EXAMINER HAS REVIEWED THIS FORM WITH ME. I UNDERSTAND THAT FALSIFICATION OF AND/OR FAILURE TO PROVIDE ANY INFORMATION IS GROUNDS FOR IMMEDIATE DISMISSAL OR COULD RESULT IN DENIAL OF WORKERS COMPENSATION BENEFITS. I ALSO UNDERSTAND THAT THE JOB OFFER IS CONTINGENT UPON SUCCESSFUL COMPLETION OF AND VERIFICATION OF DATA PROVIDED IN THE POST OFFER SCREENING. I AUTHORIZE MEDICAL INFORMATION OBTAINED DURING MY SCREENING MAY BE DISCLOSED ONLY TO THE EXTENT NECESSARY, TO DETERMINE MY ABILITY TO PERFORM ESSENTIAL FUNCTIONS OF MY INTENDED POSITION. I UNDERSTAND THAT THIS SCREENING IS COMPLETED TO DETERMINE MY ABILITY TO PERFORM ESSENTIAL FUNCTIONS OF MY INTENDED POSITION AND DOES NOT CONSTITUTE A COMPLETE AND COMPREHENSIVE MEDICAL EXAMINATION. IT IS NOT INTENDED FOR USE TO DETERMINE THE STATUS OF MY OVERALL PERSONAL HEALTH.

Signature: _______________________________________________________________________ Date: _____________________

Examiner Print Name: _____________________________________________________________ Date: _____________________

Examiner Signature: _______________________________________________________________ Time: ____________________


Name: ________________________________________________

Page 6 of 6 • BHSF #6151 Rev. 2/22/16

of 2 Form # 6109 Rev. 12/12

EMPLOYEE HEALTH SERVICESCONSENT to DRUG & ALCOHOL SCREENING

ANDRELEASE of BAPTIST HEALTH SOUTH FLORIDA

Print Name: ___________________________________ EMPLOYEE ID #:_____________ D.O.B.:____________

Statement of Policy

BaptistHealthSouthFloridaiscommittedtocreatingandmaintainingaworkplacefreeofsubstanceabuse.To that end, Baptist Health has developed a policy regarding the illegal use of drugs and the abuse of alcoholorprescriptiondrugsthatwebelievebestservestheinterestsofallemployees.Theillegaluseofdrugsorabuseofalcoholorprescriptiondrugswillnotbetolerated.ItisaviolationoftheBaptistHealthSouth Florida Drug-Free Workplace Policy for any applicant or employee to: 1) use, possess, sell, trade, offerforsale,oroffertobuyillegaldrugsorotherwiseengageintheillegaluseofdrugsonthejob;2)toreport toworkunder the influenceof illegaldrugsoralcohol; and3) touseprescriptiondrugs illegally.However,nothinginthispolicyprecludestheappropriateuseoflegallyprescribedmedications.EmployeesareadvisedthatthefollowingareunacceptableexplanationsforapositiveconfirmedtestresultandwillberejectedbytheMRO:1)expiredprescriptions(i.e.prescriptionswhichareolderthanone(1)yearfromthedate of the prescription and are unaccompanied by documentation from prescribing physician indicating continuedsuperviseduse);2)prescriptionswhicharewrittenforanyoneotherthantheemployee;3)over-thecounterherbalsupplementscontainingundisclosedcontrolledsubstancesforwhichtheemployeedoesnothaveavalidprescription;or4)over-the-countercontrolledsubstancespurchasedinaforeigncountry.

NOTE: EMPLOYEES ARE RESPONSBLE FOR ASKING THEIR DISPENSING PHARMACISTS ABOUT THE PHYSICAL AND MENTAL EFFECTS OF ANY MEDICATIONS, INCLUDING SIDE EFFECTS.

Conditions of Employment

AlljobapplicantsandemployeesmustexecutethisconsentandreleaseandmustcomplywiththetestingproceduresofBaptistHealthSouthFloridabeforetheywillbeconsideredforemployment.Applicantswhorefuse to execute this consentwill not be considered for employment byBaptistHealthSouthFlorida.Employeeswhorefusetoexecutethisconsentmaybesubjecttotermination.Noguaranteeismadethatanapplicantwhopassesthetestswillbehired.Applicantsoremployeeswhotestpositivefordrugsoralcoholmaybedeniedemploymentorsubjecttodisciplinaryaction,uptoandincludingtermination.

Confidentiality

All information, interviews, reports,statements,memoranda,anddrug test results,writtenorotherwise,receivedorproducedasaresultofBaptistHealthSouthFlorida’sdrug-testingprogramareconfidentialandwillbemaintainedintheemployee’sEmployeeHealthServicesfile.BaptistHealthSouthFloridawillnotreleaseanyinformationconcerningdrugtestresultswithoutawrittenconsentformsignedvoluntarilybythepersontested,unlesssuchreleaseiscompelledbyanadministrativelawjudge,ahearingofficer,oracourtofcompetentjurisdictionpursuanttoanappealtakenunderDrug-FreeWorkplaceAct(F.S.§440.102)orisdeemed appropriate by a professional or occupational licensing board in a related disciplinary proceeding.

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Consent For Release of Drug & Alcohol Screening Results For Licensed Healthcare Practitioners

Iunderstandandacknowledgethat,ifIamaLicensedHealthcarePractitioners,(anypersonlicensedunderchapter457;chapter458;chapter459;chapter460;chapter461;chapter462;chapter463;chapter464;chapter465;chapter466;chapter467;partI,partII,partIII,partV,partX,partXIII,orpartXIVofchapter468;chapter478;chapter480;partIIIorpartIVofchapter483;chapter484;chapter486;chapter490;or chapter 491, Florida Statutes), I shall execute, prior to drug testing, a Consent For Release of Drug &AlcoholScreeningResults.ThepurposeofthisdisclosureissothatBaptistHealthSouthFloridaandImayfulfillourlegalandethicalobligationspursuanttoFloridaStatutesChapters456and464toreportlicenseeswhoareinviolationoftheseacts.ThisConsentforReleaseofDrug&AlcoholScreeningResultsauthorizesBaptistHealthSouthFloridatoreleasetheresultsofdrug&alcoholtestingonlytothefollowingagencies:1)theFloridaDepartmentofHealth;2)theInterventionProjectforNurses(“IPN”);and/or3)theProfessionalsResourceNetwork(“PRN”);or4)asmayberequiredpursuanttoFloridaStatutes§440.102.Thisconsentwillbe ineffect from thedateofexecutionof theConsent forReleaseofDrug&AlcoholScreeningResultsuntilthelatterofthefollowing:1)thesuccessfulcompletionofanIPNorPRNprogram;or 2) the conclusion of any investigation related hereto by the Florida Department of Health.

Consent to Submit to Test

I hereby consent to submit to the testing for drugs and/or alcohol as shall be determined by Baptist Health South Florida, for the purpose of determining the drug and/or alcohol content thereof.

IagreethatBaptistHealthSouthFloridamaycollectthespecimensforthesetestsandmayforwardthemtoalicensedorcertifiedlaboratorydesignatedbyBaptistHealthSouthFloridaforanalysis.Ifurtheragreeto and hereby authorize the release of said test results to Baptist Health South Florida.

I understand that my current use of drugs and alcohol in violation of Baptist Health South Florida’s Drug-Free Workplace Policy may prohibit me from being employed at Baptist Health South Florida, or may subjectmetodisciplinaryaction,uptoandincludingterminationofemployment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.

I releaseBaptistHealthSouthFloridaandits trustees,officers,employeesandagentsfromanyandallclaims,liabilitiesandcausesofactionofanynaturewhatsoeverinconnectionwitha)thisconsent,b)theperformingofdrugandalcoholtestinconnectiontherewithandc)mynotbeingemployedbyBaptistHealthSouthFloridaif,inthesoleopinionofBaptistHealthSouthFlorida,IfailtomeetanyoftherequirementsestablishedbyBaptistHealthSouthFloridainconnectionwithsuchtests.

Ihavecarefullyreadtheforegoingandfullyunderstanditscontents.Iacknowledgethatmysigningofthisconsent and release form is a voluntary act on my part.

Dated this ____________ day of ___________________ 20____.

Signature of Applicant/Employee Print Name of Applicant/Employee

Name and Title of Witness (PRINT CLEARLY) Signature of Witness

Page 2 of 2 Form # 6109 Rev. 12/1210

BHSF #6149 Rev. 12/12

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NAME:__________________________________ Last4digitsofSS#:_______________________

LATEXALLERGYHISTORYSCREENINGHave you ever had a reaction such as swelling, itching or difficulty breathing when exposed to latex material like rubber gloves or balloons? Yes £ No £

Describe any reactions (redness, itching, burning rash, difficulty breathing, wheezing, facial swelling, nasal congestion, tearing, shock) you may have had to the following materials or foods:

YesNo DescribeBalloons £ £ ____________________________________________________________________Rubber Gloves £ £ ____________________________________________________________________Band-Aids £ £ ____________________________________________________________________Adhesive Tape £ £ ____________________________________________________________________Elastic Materials £ £ ____________________________________________________________________Dental Devices £ £ ____________________________________________________________________Condoms £ £ ____________________________________________________________________Avocados £ £ ____________________________________________________________________Bananas £ £ ____________________________________________________________________Kiwi Fruit £ £ ____________________________________________________________________Papayas £ £ ____________________________________________________________________Chestnuts £ £ ____________________________________________________________________Other: _____________ £ £ ____________________________________________________________________

Doyouhaveahistoryofanyofthefollowing? Yes No Yes No £ £ Itchy eyes / nose, nasal congestion £ £ Eczema £ £ Asthma £ £ Difficulty breathing, cough £ £ Skin Rashes £ £ Nasal/ sinus congestion and eye irritation £ £ Autoimmune Disease £ £ Drug Allergy £ £ Numerous Medical/Surgical Procedures £ £ Occupational exposure to Latex Products £ £ Congenital abnormality (such as spina bifida) £ £ Severe or unexplained reactions (shock) during medical or dental work

Have you ever been diagnosed with a Latex allergy in the past? £ No £ Yes If yes, please provide date and name of provider:__________________________________________________________________________________________________________

Have you previously been compensated or disabled due to a latex allergy or allergic reaction to latex? £ No £ Yes If yes, please provide the dates, the name of the medical providers/facilities and insurance companies involved (if any) and the circumstances surrounding that prior period of disability and/or compensation: ______________________________________________________________________________________________________________________________________________________

Haveyoueverhadanyofthefollowing? Yes No £ £ General Allergy Testing: Results: _____________________________________________________ £ £ Latex-Allergy Testing: Results: _____________________________________________________ £ £ Allergy Treatment: Describe: ____________________________________________________

List the names of all allergists, dermatologists, internists and/or primary care physicians who have treated you in the past for any allergic conditions or prescribed any medications for allergies: Doctors’ names and phone numbers: ____________________________________________________________________________

Additional comments: ________________________________________________________________________________________

Employee/Applicant Signature: ________________________________________ Date:_______________

Healthcare Provider Initials: _______________ Date:_______________

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Employee Health Services

MEDICAL QUESTIONNAIRE FORRESPIRATOR USERS

PART A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by the employee who has been selected to use any type of respirator (please check “Yes” or “No”).

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: G Yes G No

2. Haveyoueverhadanyofthefollowingconditions?

a. Seizures(fits): G Yes G No

b. Diabetes (sugar disease): G Yes G No

c. Allergicreactionsthatinterferewithyourbreathing: G Yes G No

d. Claustrophobia (fear or closed in places) G Yes G No

e. Trouble smelling odors: G Yes G No

3. Haveyoueverhadanyofthefollowingpulmonaryorlungproblems?

a. Asbestosis: G Yes G No

b. Asthma: G Yes G No

c. Chronic bronchitis: G Yes G No

d. Emphysema: G Yes G No

e. Pneumonia: G Yes G No

f. Tuberculosis: G Yes G No

g. Silicosis: G Yes G No

h. Pneumothorax (collapsed lung): G Yes G No

i. Lung cancer: G Yes G No

j. Brokenribs: G Yes G No

k. Anychestinjuriesorsurgeries: G Yes G No

l. Any other lung problem that you’ve been told about: G Yes G No

Page1of2•BHSF6126Rev.1/25/16

Today’s Date: ___________________

Name: _______________________________________________________________________ Emp. ID#: ______________________

Job Title: __________________________________________________________ Last 4 digits of Emp. SS#: ______________________

Sex (Check one): G Male / G Female D.O.B.: ________________________ Height: ______ ft. ______ in. Weight: ____________ lbs

T Aphonenumber(includingareacode)whereyoucanbereachedbythehealthcareprofessionalwhoreviewsthisquestionnaire:

______________________________________________________________________________________________________

T What is the best time to phone you at this number: _____________________________________________________________

Hasyouremployertoldyouhowtocontactthehealthcareprofessionalwhowillreviewthisquestionnaire

(pleasecheck“Yes”or“No”)? G Yes G No

1. Checkthetypeofrespiratoryouwilluse(youmayselectmorethanonecategory): a. GN.R.orPdisposablerespirator(e.g.filter-mask,non-cartridgetypeonly) b. GOthertype(e.g.half-orfull-facepiecetype,powered-airpurifying,supplied-air,self-containedbreathingapparatus)

2. Haveyouwornarespirator(pleasecheck“Yes”or“No”)? G Yes G No

If“Yes”whattype(s): _________________________________________________________________________________________

___________________________________________________________________________________________________________

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MEDICAL QUESTIONNAIRE FOR RESPIRATOR USERS continued . . . 4. Doyoucurrentlyhaveanyofthefollowingsymptomsofpulmonaryorlungillness? a. Shortness of breath: G Yes G No b. Shortnessofbreathwhenwalkingfastonlevelgroundorwalkingupaslighthillorincline? G Yes G No c. Shortnessofbreathwhenwalkingwithotherpeopleatanordinarypaceonlevelground: G Yes G No d. Havetostopforbreathwhenwalkingatyourownpaceonlevelground: G Yes G No e. Shortnessofbreathwhenwashingordressingyourself: G Yes G No f. Shortnessofbreaththatinterfereswithyourjob: G Yes G No g. Coughing that produces phlegm (thick sputum): G Yes G No h. Coughingthatwakesyouearlyinthemorning: G Yes G No i. Coughingthatoccursmostlywhenyouarelyingdown: G Yes G No j. Coughingupbloodinthelastmonth: G Yes G No k. Wheezing: G Yes G No l. Wheezingthatinterfereswithyourjob: G Yes G No m. Chestpainwhenyoubreathedeeply: G Yes G No n. Any other symptoms that you think may be related to lung problems: G Yes G No

5. Haveyoueverhadanyofthefollowingcardiovascularorheartproblems? a. Heart attack: G Yes G No b. Stroke: G Yes G No c. Angina: G Yes G No d. Heart failure: G Yes G No e. Swellinginyourlegsorfeet(notcausedbywalking): G Yes G No f. Heart arrhythmia (heart beating irregularly): G Yes G No g. High blood pressure: G Yes G No h. Any other heart problem that you’ve been told about: G Yes G No

6. Haveyoueverhadanyofthefollowingcardiovascularorheartsymptoms? a. Frequentpainortightnessinyourchest: G Yes G No b. Pain or tightness in your chest during physical activity: G Yes G No c. Painortightnessinyourchestthatinterfereswithyourjob: G Yes G No d. Inthepasttwoyears,haveyounoticedyourheartskippingormissingabeat: G Yes G No e. Heartburn or indigestion that is not related to eating: G Yes G No f. Any other symptoms that you think may be related to heart or circulation problems: G Yes G No

7. Doyoucurrentlytakemedicationforanyofthefollowingproblems? a. Breathing or lung problems: G Yes G No b. Heart trouble: G Yes G No c. Blood Pressure: G Yes G No d. Seizures(fits): G Yes G No

8. Ifyou’veusedarespirator,haveyoueverhadanyofthefollowingproblems?

If you have never used a respirator, CHECK the following and go directly to Question 9. G N/A a. Eye irritation G Yes G No b. Skin allergies or rashes G Yes G No c. Anxiety: G Yes G No d. Generalweaknessorfatigue: G Yes G No e. Anyotherproblemthatinterfereswithyouruseofarespirator: G Yes G No

9. Wouldyouliketospeaktothehealthcareprofessionalwhowillreviewthisquestionnaire: G Yes G No

If you experience any chest pain, shortness of breath, lightheadedness, diaphoresis or anxiety while wearing the PFR- N95 Respirator, remove the respirator IMMEDIATELY and report the symptoms to Employee Health.

**DO NOT attempt to wear the PFR N-95 mask until your symptoms have been reported and evaluated by Employee Health.**

MedicallyclearedbyEmployeeHealthtowearPFR-N95: ___________________________________________ _______________ Print Name Date

___________________________________________ _______________ Signature Time

Page2of2•BHSF6126Rev.1/25/16

EMPLOYEE HEALTH OFFICEORDER SHEET

Location (check one): £ Baptist £ South Miami £ Doctors £ WKBH £ Homestead £ Mariners £ BOS/BHE £ Corporate

Employee name _________________________________________________________ Age _______ Birth Date _________________

Home address ________________________________________________________ Zip Code _________ Marital status __________

Phone (home/cell) _________________________________________________ Last 4 digits of Social Security #: XXX - XX - _______

Doctor’s Name _____________________________________________________

Gender: £ Male £ Female Religion: ________________________ £ Pre-Employment

Race: £ American Indian/Alaskan £ Asian £ Black £ Black Hispanic £ Unknown/Declined £ Other

£ Hawaiian/Pac.Island £ White £ White Hispanic

Guarantor: £Healthoffice £ Workers’ Comp. £ Employee

TEST REQUESTED

Form #1695-A (Rev. 11/4/16)

TESTS NOT LISTED ____________________________________________________________________________________________

________________________________________________________________________________________________________________

COMMENTS ____________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

___________________________________________________________________________ _________________________________HealthOfficeProvider(printname) Date

___________________________________________________________________________ _________________________________Signature,HealthOfficeProvider Time

*12200B1695*

Order Set _______________ OS Exposure Panel (Employee) - IncludesHepatitisBSurfaceAbs,HepatitisCAbs,HIVAbstest(1&2)

LAB Chemistry ____________ Chemistry Panel (CMP-14)

____________ Chemistry Panel (BMP-8)

____________ Lipid Panel (Cholesterol, Triglyceride, HDL, LDL)

____________ Glucose (Fasting)

____________ Glucose (Random)

____________ Hepatitis A Antibody ____________ Hepatitis B Surface Antigen ____________ Hepatitis B Surface Antibody ____________ Hepatitis B Core Antibody ____________ Hepatitis C Antibody ____________ ALT (SGPT)

____________ AST (SGOT)

____________ Hepatic Function Panel (Liver Function Test)

____________ HIV ABS TEST (HIV1&2) ____________ TSH ____________ High Sensitivity CRP ____________ Hgb A1C ____________ Pregnancy Test-HCG (Urine)

____________ UrinalysiswithReflexCulture

Hematology ____________ CBC ____________ CBC (includesPlatelet)&DIFF

Serology ____________ Rubella IGG Immune Status ____________ Rubeola (Measles) IGG Immune Status ____________ Varicella Zoster IGG Immune Status ____________ Quantiferon TB Gold

Radiology ____________ AP&LateralChest ____________ Cervical Spine ____________ Thoracic/Dorsal ____________ Lumbar Sacral

Other ____________ EKG

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*12200B1695*

CONSENT TO TREATMENTI consent to all medical and surgical procedures and treatment, including but not limited to surgery, medical treatment, radiological examination, anesthesia, laboratory procedures, inpatient or outpatient services, and medications that may be performed,administeredorrenderedbyorunderthespecificorgeneralinstructionsofmyormychild’sphysiciansorsurgeonsduring this hospitalization or outpatient visit. In addition, I agree to abide by facility regulations designed to enhance the care and safety of patients, and I consent to the appropriate disposal of any specimen or other bodily materials removed during the course of my or my child’s treatment.

CONSENTIMIENTO PARA TRATAMIENTODoymiconsentimientoatodosycualquierprocedimiento,tratamientomedico,quirurgicosotratamientoquaincluyan,perono esten limitados a, cinugia, tratamiento medico, examinacion radiologica, anesthesia, servicios de laboratorio, servicios de “inpatientooutpatient”ymedicinasquepuedenserrealizados,administradosodadosporobajolasinstruccionesespecificaso generales del personal medico o de cirugia durante esta hospitalizacion o visita como paciente externo. Ademas, acuerdo aceptarlasregulacionesdeestecentro,regulacionesqueestandisenadasparafacilitarelcuidadoylasseguridaddelospacientesy,ademas,consientoalprocedimientoestablecidoparadisponerdecualquierespecimenodemiembrosremovidosduranteelcursodeltratamientodadoamipersonaoalademi(s)hijo(s)menores.

RELEASE OF INFORMATIONIauthorizethefollowingindividuals/healthcareproviderstoreleasecopiesofinformationintheirpossession,acquiredinthecourseofmyormychild’sexaminationandtreatment,tomyinsurancecarriersinconnectionwithmytreatmentforthepurposeof any insurance, Medicare or Medicaid payments:

-Thisfacilityanditsaffiliates -Utilizationreviewagenciesorauditors- Physicians - Other allied health professionals (Attending and Consulting)

PROPAGACION DE INFORMACIONAutorizo a los siguientes individuos/provedores de servicios de salud a dar copias de informacion sobre mi examen y tratamiento,oelexamenytratamientodemi(s)hijo(s)menores,ami(s)compania(s)desegurosconelprepositodepagosdeseguro, Medicare o Medicaid:

-EsteCentroysusafiliados -AgenciasoAuditoresde“Revisiondeutilizacion”-Medicos -Cualquierotroprofesionalsanitario (Primarios o consultores)

NOTICE OF PRIVACY PRACTICE AND RELEASE OF INFORMATIONIacknowledgethatIwasprovidedwithacopyoftheBaptistHealthNoticeofPrivacyPracticesdescribinghowBaptistHealthmayuseanddisclosemyhealthinformationunderthefederallaw.ProvidedthatBaptistHealthcontinuesitsgoodfaithefforttocomplywiththerequirementsofthefederalprivacylaw,Iherebyconsenttotheuseanddisclosureofmyhealthinformationforthepurposesandactivitiespermittedunderthefederalprivacylaw,whicharedescribedintheBaptistHealthNoticeofPrivacy Practices.

NOTIFICACION SOBRE LAS PRACTICAS DE PRIVACIDAD Y DIVULGACION DE INFORMACIONAcusoreciboquemehandadounacopiadelanotificacionsobrelasPracticasdePrivacidaddeBaptistHealthdescribiendocomo el Baptist Health segun la ley federal puede utilizar y dar a conocer informacion sobre mi salud. Siempre y cuando el BaptistHealthcontinuedebuenafeenesforzarseporcumplirconlosrequisitosdelaleyfederaldeprivacidad,consientomedianteelpresenteaqueseutiliceysedeaconocerinformacionsobremisaludparalospropositosyactividadespermitidoporlaleyfederaldeprivacidad,lacualsedescribeenlaNotificacionsobrelaspracticasdePrivacidaddeBaptistHealth.

____________________________________ XXX - XX - ____________Print Name/Nombre en letras de imprenta Last 4 Digits of SS#/ Últimos 4 dígitos del Seguro Social

____________________________________ __________ ____________________________________ __________Signature/Firma Date/Fecha Witness/Testigo Date/Fecha

Form #1695-B (Rev. 11/4/16)*10600B1695**12200B1695*

15

16

o Baptist o South Miami o Doctors o Homestead o Mariners o BOS / BHE o Corp

NAME: _______________________________________________ Last 4 Digits of SS#: XXX - XX - _________

I agree to abide by the policy of Baptist Health South Florida (BHSF) prohibiting the use, possession or sale of non-prescribednarcotics,perceptualdistorters,depressants,stimulants,marijuana,orothercontrolledsubstances.IunderstandthatevidenceofillegaldrugusagecouldaffectmyemploymentwiththeHospitalandIagreetoabidebyany decision made by the Hospital in this regard, I hereby give my voluntary consent to be medically examined and toprovideabloodand/orurinesamplewhichmaybetestedfordrugsoralcohol.Icertifythatthespecimengivenismy blood and/or urine, and that it is voluntary given for the purpose of the drug screen.

• Doyoucurrentlyuseprescribedornon-prescribedcontrolledsubstancesincludingnarcoticspainkillers,tranquilizers,sleepingmedication,appetitesuppressants,orotherstimulants?_________

• Haveyouusedanynon-prescribedcontrolledsubstancewithinthepast(a)six(6)months_________or, (b)five(5)years?_________

• Areyounowusinganyillegalcontrolledsubstances,includingheroin,cocaine,designerdrugs,perceptualdistorters,marijuanainanyform,orinhalants?_________

Please list ALL over the counter drugs (such as cough medicine, antihistamines, and anti-diarrheals) and prescription medication (including injections) you have taken (received) in the last four (4) weeks below.

OVER the COUNTER DRUGS / PRESCRIPTION DRUGS

Employee Health ServicesDRUG SCREEN NOTIFICATION OF MEDICATION(S)

SPECIFICBRAND NAME

MEDICATION/DRUG

REASON forMEDICATION

DOSAGESTRENGTH

per DAY

DATE and TIME of

LAST DOSE

HOW MANY DAYS USED

NameandaddressofPhysicianwhoprescribeddrug(s): ______________________________________________

____________________________________________________________________________________________Iherebyaffirmthattheinformationsetforthhereinistruetothebestofmyknowledgeandbelief,andIunderstandthiswillbecomeapartofmymedicalrecord.Iagreethatthatanyfalsestatementormisrepresentationonthisformsubjectsmeto ineligibilityforhire,andtodismissal ifhired.Further, IherebyreleaseandagreetoholdharmlessBaptistHealthSouthFlorida,itsofficer,agentsandemployeesfromanyliabilityconnectedwiththedrugscreenandthe use of the results thereof. I consent to take the drug screen.

Print Applicant/Donor’s Name: _______________________________________ Date: _____ / _____ /______

Applicant/Donor’s Signature: ________________________________________

Witness: ________________________________________________________

BHSF 6152 Rev. 2/7/1610800Y6152

BAPTIST HEALTH SOUTH FLORIDA

DRUG SCREEN NOTIFICATION OF MEDICATION(S)

*10800Y6152*

17

BHSF 6202 Rev. 2/7/1613025Y6202*13025Y6202*

PRE-EMPLOYMENT HEPATITIS-B IMMUNIZATION INFORMATION

Job Location: Please R (1) Box

q Baptist q South Miami q Doctors q WKBH q Homestead q Mariners q BOS / BHE q Corporate

Print Name: ____________________________________________________ Date: ______ / _____ / ________

Date of Birth: ____________________________ Last 4 Digits of SS#: ____________________________

Department: _______________________________ Position: ________________________________________

Home Phone: (_____) _____ - ______ Cell Phone: (_____) _____ - _____ Other Phone: (_____) _____ - _______

**************************************************************************************************************

Hepatitis-B Vaccine is offered to all employees having patient care contact and whenever other circumstances warrant it. High-risk areas are defined as all persons having contact with blood or body fluids.

Hepatitis-B Vaccine is a new genetically engineered vaccine. It is safe and effective and is not derived from human plasma. The vaccine is made from Brewer yeast.

During my post-offer health screening, I was advised of the above procedure. I had the opportunity to discuss it with the interviewing nurse. In addition, I was given literature regarding Hepatitis-B Vaccine.

If I accept a position at Baptist Health of South Florida, I will make an appointment to be seen within a week of my arrival to inform the Health Office nurse whether or not I wish to take advantage of this immunization. If I do not want the vaccine, I must sign a statement to that effect.

Applicant / Employee Signature: _________________________________ Date: _________________

Witness Signature: ____________________________________________ Date: _________________

18

BHSF 6203 Rev. 2/7/1611500Y6203*11500Y6203*

PRE-EMPLOYMENTPARTICULATE FILTER RESPIRATOR INFORMATION SHEET

Job Location: Please R (1) Box

q Baptist q South Miami q Doctors q Homestead q Mariners q BOS / BHE q Corporate

Print Name: ____________________________________________________ Date: ______ / _____ / ________

Date of Birth: ____________________________ Last 4 Digits of SS#: ____________________________

Department: _______________________________ Position: ________________________________________

Home Phone: (_____) _____ - ______ Cell Phone: (_____) _____ - _____ Other Phone: (_____) _____ - _______

**************************************************************************************************************

A Particulate Filter Respirator, (PFR-N95 MASK) is required to be worn by all employees having direct patient care/contact where there is a risk of exposure to Mycobacterium Tuberculosis (MTB).

During my Pre-Employment screening, I have been advised of the above policy and availability/requirement by NIOSH (National Institute for Occupational Safety and Health) for the use of the respirator mask. Baptist Hospital health care employees who meet the above criteria are to be fit tested for a Particulate Filter Respirator-PFR-N95.

I have been given literature to review regarding this mask, and have had the chance to discuss it with the interviewing Nurse.

Applicant / Employee Signature: _________________________________ Date: _________________

Witness Signature: ____________________________________________ Date: _________________

19

BAPTIST HEALTH SYSTEMSN-95 PARTICULATE FILTER

RESPIRATOR MASK (N-95 PFR)

G Iwearasize:__________________N-95 PARTICULATE FILTER RESPIRATOR MASK (N-95 PFR)

G IunderstandthatImustfitcheckthesealoftheN-95respiratormaskpriortoeachuse.ToplacetheN-95PFRrespiratormaskproperlyonmyfaceonestrapistobeplacedabovetheearandtheotherstrapgoesbelowtheearandthemaskisthenmoldedto my face.

G Iunderstand thatafitcheck isperformedby takingadeepbreath inand thenexhalingrapidly throughmymouth. Ifairis feltescapingfromaroundtheseal,themaskisreadjustedandthesameprocedureisrepeateduntilasealhasbeenestablished. This is to be done each time I place the N-95 PFR respirator mask on.

G IunderstandIamrequiredtoweartheN-95PFRrespiratormaskformyprotectionwhencaringforpatientswhoareonAirBorneisolationorwhenassisting / performing High Risk procedures (endotracheal suctioning / bronchoscopy) in patients suspected of having Tuberculosis.

G IunderstandifIloseorgainweight,havefacialsurgery,dentalworkoranyprocedurethatalterstheshapeofmyfaceandIamunabletosuccessfullycompleteafitcheck,IwillgotoEmployeeHealthServicestobere-fittested.

G IunderstandthatifIhaveanyfacialhairorbeardthatpreventsdirectcontactbetweenmyfaceandtheN-95PFRrespiratormaskIcannotwearthemask.

G Iwillnotknowinglyallowanotheremployee,whohasnotbeenfittested,intoanAirborneIsolationroom.IwillinsteadinstructthemtobefittestedinEmployeeHealthServices.IunderstandthatneitherthepatientnorfamilymembersaretoweartheN-95PFRrespirator mask.

G IunderstandthatifanAirborneisolationpatientistransportedtoanotherdepartment,thepatientistoweararegularsurgicalmaskand the mask should be changed about every 20 minutes to prevent aerosolization.

G IunderstandthatwhenthepatientonAirborneIsolationgoesoutsidetheisolationroomandwearsaregulartiesurgicalmaskthereisnoneedformetoweartheN-95PFRrespiratormask.IftheAFBisolationpatientisnotwearingthemaskIamtowearthe N-95 PFR respirator mask.

G IunderstandthatonlyoneN-95PFRrespiratormaskisrequiredforanentireshift(8to12hours)andthesamemaskmaybewornwhencaringformultipleAFBisolationpatients.

G IunderstandthatshouldtheintegrityoftheN-95PFRrespiratormaskbecomecompromised(becomessoiled,wetorthesealcannolongerbemaintained)IshoulddisposeofthemaskandobtainanewN-95PFRrespirator.

G IunderstandwhendisposingoftheN-95PFRrespiratoritcanbeplacedintheregulartrashunlessitissoiledwithvisiblebloodorbodyfluids(ThenIwillplaceitintheredbiomedicaltrashcontainer).

G IunderstandthatshouldIexperienceanychestpain,shortnessofbreath,light-headedness,diaphoresis,oranxietywhilewearingthePFRN-95Respirator,IamtoremovetheRespiratorASAPandreportthesymptomstotheEmployeeHealthOffice.IwillnotattempttowearthePFRn-95maskuntilmysymptomshavebeenreportedtoandIhavebeenevaluatedbytheEmployeeHealthOffice.

G IhavereadandansweredtheabovequestionsandhavebeengivenanopportunitytoaskquestionsregardingtheuseoftheN-95 PFR respirator mask.

Employee Name: ____________________________________________________________________ Date: __________________

Employee Signature: _________________________________________________________________ Time: _________________

Employee Health Services Representative’s Name: _________________________________________ Date: __________________

Representative’s Signature: ___________________________________________________________ Time: _________________

Designation: White - Employee Health, Canary - EmployeeBHSF 6122 Rev. 4/10

*11500Y6122**11500Y6122*

20

Pre-Employment ServicesCarbon Monoxide Testing Consent

Form #5342 Rev. 11/13

AtPre-EmploymentServices,newhiresor,inlimitedcases,existingemployeesareofferedtheopportunitytotake a Carbon Monoxide Breath test to determine their carbon monoxide status. Agreeing to take this voluntary testwillhelpusdetermineyoureligibilitytoreceivea$50creditperpayperiodonyourBaptistHealthSouthFlorida medical plan employee contribution. If your results are negative for carbon monoxide and you have no coveredadultdependentswhousetobacco,youwillreceivethecredit.Ifyourresultsarepositiveforcarbonmonoxideandyouarenotasmoker,youwillhavetheoptiontotakeanicotineurinetesttoconfirmyoursmokerstatus.Youwillbeineligibleforthemedicalplanemployeecontributioncreditifyoutestpositivefornicotine.AllsmokerswillreceiveaBHSFWellnessAdvantageStopSmokingpacketenclosedwithinformationaboutourSmokingCessationPrograms.Enrollingandcompletinganyoftheseprogramswithintherequiredtimeframewillallowustoupdateyourstatusasanon-smoker.

Print Name: _______________________________________ D.O.B. _____________ Last 4 Digits of SS# _________

By signing this form, I am giving consent to the Pre-Employment clinician to conduct a Carbon Monoxide Breath testtodeterminemycarbonmonoxidestatus.IunderstandthatmytestresultswillbesubmittedtoWellnessAdvantagefortracking,andcommunicatedtotheBenefitsDepartmentfordeterminingmyBHSFmedicalplanemployeecontribution.AlloftheinformationIprovideisstrictlyconfidential.Anypapercopiesofmyinformationwillbemaintainedinlockedfileswithlimitedaccess.

Employee Signature: _____________________________________________ Date: ____________________

Pre-Employment clinician: _________________________________________ Date: ____________________

To be completed by EHS Staff Carbon Monoxide Test Result: £ CO Negative £ CO Positive

Distribution: White-EmployeeHealth/Yellow-Candidate

pre-employment health packet · pre-employment health packet. ... official employee health use only...

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