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       Before proceeding, please read the helpful instructions below on how to fill out the following forms:

Revised: 08/2021

  

PO BOX 148, RENSSELAER, NEW YORK 12144
PHONE (518) 449–1142 FAX (518) 449–1320

PRE-EMPLOYMENT HEALTH QUESTIONNAIRE

To Be Completed By The Employee
I.    
II.   Please check if you have had any of the following:
 
Severe Headaches Vision Impairment Speech Impairment
Fainting / Dizzy Spells Hearing Difficulties Convulsions / Seizures
Frequent Sore Throat Frequent Colds Allergies
Chest Pain / Pressure Heart Problems Shortness of Breath
Asthma Pneumonia Chronic Cough
Poor Appetite Chronic Indigestion Recurrent Nausea
Recurrent Vomiting Vomiting of Blood Chronic Constipation
Black / Bloody Stools Bowel Problems Freq. / Painful Urination
Blood in Urine Kidney Stones / Disease Swollen Ankles
Back Problems Arthritis High Blood Pressure
Low Blood Pressure Diabetes Jaundice
Hepatitis Stomach Ulcers Hernia or Rupture
Communicable Disease Staph / Strep Infection Skin Allergies / Disease
Varicose Veins Blood Dyscrasia Alcoholism
Drug Addiction Mental Illness Cancer or Tumors
Injuries Operations Other
III.   Medical History:
A.     Are you under the care of a physician?          
B.     Have you been recently hospitalized?            
C.     Are you taking any medications?                    
D.     Do you have any physical limitations?            
 

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PO BOX 148, RENSSELAER, NEW YORK 12144
PHONE (518) 449–1142 FAX (518) 449–1320

IMMUNIZATION STATUS
Document the date of vaccine given -or- titer given and results:
MANDATED TEST    
PPD / TB Test
Manufacturer:
Lot #:                

Expiration Date:

-OR-
Chest X-ray (if positive PPD)
COPY OF CXR IS REQUIRED
Negative         Positive		 STEP 1
Date given:
   Date read:

Negative(0mm)         Positive

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 STEP 2
Date given:
   Date read:

Negative(0mm)         Positive

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Rubella
Vaccine

Titer		 Vaccine date:
COPY OF SEROLOGY REPORT IS NEEDED IF A BLOOD TEST IS DONE
Rubeola
Vaccine

Titer		 Vaccine #1 date:


Vaccine #2 date:
COPY OF SEROLOGY REPORT IS NEEDED IF A BLOOD TEST IS DONE
Two doses of the live virus measles vaccine are required for individuals born on or after January 1, 1957. The second vaccine must be administered more than 30 days after the first vaccine given.
NOT MANDATED DATE RESULTS
Hepatitis B Titer   Immune    Not Immune
Hepatitis B Vaccine Vaccine #1 date:


Vaccine #2 date:


Vaccine #3 date:
Immune    Not Immune
I certify that this person is free from a health impairment which is of potential risk to others, or which might interfere with the performance of his/her duties including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior.

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PO BOX 148, RENSSELAER, NEW YORK 12144
PHONE (518) 449–1142 FAX (518) 449–1320

COVID VACCINATION AND BOOSTER INFORMATION
Yes     No
COVID Vaccine Information:
COVID Vaccine Type:   Pizer        Moderna       J&J

Dates of Covid vaccines:
Date of 1st COVID Vaccination:
Date of 2nd COVID Vaccination (unless J&J):
Yes     No
Dates of COVID Booster 1:
Date of COVID Booster 2:
Date of COVID Booster 3:

Revised: 08/2021

  

PO BOX 148, RENSSELAER, NEW YORK 12144
PHONE (518) 449–1142 FAX (518) 449–1320

TUBERCULIN RISK ASSESSMENT AND SCREENING
Name:
TB Screening:

1.   Temporary or permanent residence for > 1 month in a country with a high TB rate         
2.   Current or planned immunosuppression, including HIV, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g. infliximab, etanercept, or other), chronic steroids (equivalent of prednisone > 15mg/day for > 1 month or other immunosuppressive medication        
3.   Been in close contact with someone who has had infectious TB disease       
4.   History of active TB or latent TB infection or a positive skin test or blood test for TB        
5.   Ever been treated for TB or latent TB        
TB Symptoms: A productive cough lasting > 3 weeks, coughing up blood, unexplained weight loss, fever, chills, night sweats, persistent shortness of breath, chronic fatigue > 3 months, chest pain
1.   Does the individual exhibit any of the above signs and symptoms        

MANDATORY HEPATITIS B VACCINE DECLINATION FORM
Employee Name:

I understand that, due to my occupational exposure to blood or other Potentially infectious materials, I may be at risk of aquiring hepatitis b Virus (hbv) infection. I have been given the opportunity to be vaccinated With hepatitis b vaccine, at no charge to myself. However, I decline the Hepatitis b vaccination at this time. I understand that by declining this Vaccine, I continue to be at risk of acquiring hepatitis b, a serious disease. If in the future, I continue to have occupational exposure to blood or Other potentially infectious materials and I want to be vaccinated with The hepatitis b vaccine, I can receive the vaccination series at no charge to Me.

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DECLINATION OF INFLUENZA VACCINATION FOR HEALTH CARE PERSONNEL
Employee Name (print):

My employer, Accu Care Home Health Services, recommends that I receive the influenza vaccination to protect myself, patients, staff, and others in the healthcare facility.
I acknowledge that I am aware of the following facts (please read and check each box):

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PO BOX 148, RENSSELAER, NEW YORK 12144
PHONE (518) 449–1142 FAX (518) 449–1320

REFERENCE AND EMPLOYMENT VERIFICATION
Date:
Name of employer:
Personal: Personal reference please complete under comments
 
Add More Reference
 
Employer Name  
     
Reference Name        
Reference Email        
Reference Phone        
Dates of worked at each employer        
     
Applicant's name:                Position applied for:
Dates of employment:      From:
         TO:
Position held:
Would you rehire this person?
Pre Ormance: Above Average Average Below Average
Skill level
Cooperation
Initiative
Attendance
Attitude
Appearance
Punctuality
Honesty
Comments:
Signature of persons completing form:

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I hereby authorize the release of any information concerning previous employment / personal character to Accu Care Home Health Services, Inc.
Signature of applicant:

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Applicant: Please refold form & return to Accu Care as soon as possible.