Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges

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1 To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall (telephone) (fax) The New York Department of Health requires that complete history and physical, proof of immunity for rubella and rubeola, and surveillance for tuberculosis to be submitted prior to granting of medical staff privileges. In addition, evidence of immunity to varicella and hepatitis B are required by Upstate policy and documentation of vaccination for the current influenza season is mandated by the Hospital Executive Committee to medical staff to maintain privileges. Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges Rubella Antibody Titer (copy of the lab report is required) Rubeola Antibody Titer (if born 1/1/57 or later) - (copy of the lab report is required) Varicella evidence of immunity by one of the following: o Positive varicella antibody titer (copy of the lab report is required) o Dates of two vaccinations for varicella at least 4 weeks apart Hepatitis B Surface Antibody Titer (copy of the lab report is required) Influenza vaccination date for the current season (documentation is required) Tuberculin Skin Test (PPD) - Within 6 months of applying for privileges (prior BCG does not negate placing a TST). IGRA (blood test) for tuberculosis is also acceptable. Chest x-ray if prior tuberculin skin test has been positive, this must be done within 6 months of applying for privileges. A copy of the official report must be provided Your medical forms are reviewed only by the medical personnel of. All required documents should be submitted at one time by mail or fax to: Upstate Medical University Telephone: Fax:

2 Immunization Record Jacobsen Hall, 4th Floor Phone: Fax: Last Name First Name Middle Initial Date of Birth Today s Date The New York Department of Health requires that complete history and physical, proof of immunity for rubella and rubeola, and surveillance for tuberculosis to be submitted prior to granting of medical staff privileges. In addition, evidence of immunity to varicella and hepatitis B are required by Upstate policy and documentation of vaccination for the current influenza season is mandated by the Hospital Executive Committee to maintain medical staff privileges. Rubella: Antibody Titer: (copy of the lab report is required) Date: Result: If titer negative, date of immunization: Rubeola: Antibody Titer: (copy of the lab report is required) Date: Result: If titer negative, date(s) of immunization: Varicella: (chickenpox): One of the following indicators of immunity is required: Varicella immunizations: Date: #1: Date: #2: Varicella titer: Date: Immune: (copy of the lab report is required) Hepatitis B Surface Antibody Titer (copy of the lab report is required) Date: Result: If titer negative, date(s) of immunization: Influenza vaccination (for the current season) Date: (documentation of administration is required) Tuberculin Skin Test (PPD) (required within 6 months of assignment) TST: Date placed: Manufacturer: Lot#: Date read: Result: mm If TST Positive: Chest x-ray within 6 months of assignment is required Date: Result: (enclose a copy of report) Send or fax ( ) the completed medical history, physical examination, proof of immunity (including titer lab reports), and tuberculin skin test or chest x-ray result to. Medical clearance will be issued when all medical information has been submitted and approved Req Med Clearance Page 2 of 5 Rev. 05/2015

3 S t a t e U n i v e r s i t y o f N e w Y o r k Upstate Medical University Medical Staff History and Physical Tel Fax Last Name First Middle Initial Sex Date of Birth Today's Date Local Address (. and Street) City State Zip Social Security Number Address Phone Number Job Title Department/Unit Personal Health History Have you ever had, or do you have, any of the following? If YES, please specify by number and provide an explaination. 1. Chicken pox or shingles Measles Mumps Skin problems or chronic rash Eye problems Hearing loss or ear problems Chronic cough Asthma Shortness of breath Lung problems Tuberculosis or positive TB skin test Chest pain Heart trouble/attack Palpitations/irregular heart beat Heart murmur High blood pressure Stroke or paralysis Stomach or intestinal problem Liver disease/hepatitis Kidney disease Weight change Thyroid problems Shoulder/elbow/wrist/hand pain Numbness/tingling of arms or hands Broken bones Bone or joint problems Arthritis/gout Back pain/injury Numbness/tingling legs or feet Knee pain/injury Foot pain/injury Neck pain/injury Loss of limb Severe headaches Dizziness or fainting Epilepsy or seizures Severe weakness or tiredness Depression or anxiety Emotional or psychiatric problems Drug or Alcohol dependency Eating disorder Bleeding or blood disorder Immune suppression Chronic/recurrent infection Tumor/cancer Anemia Diabetes Any other illness not listed Req Med Clearance Page 3 of 5 Rev. 4/2008

4 NAME: Please Check Each Item, If YES, please specify by number and provide an explaination. 1. Are you on any medications Do you have any allergies to medication Do you use other drugs Do you use alcohol Refused as a blood donor Do you smoke cigarettes Have you ever been hospitalized Have you ever had surgery Have you ever received treatment or counseling for psychiatric or emotional illness Do you have allergies to certain chemicals, dust, animals, or animal products (animal dander, bedding waste) Have you ever been refused employment for health reasons Do you have visual, hearing or other physical limitations Are you unable to assume certain body positions Are you unable to perform certain motions Is there any reason you cannot fully perform all duties that your employment or volunteer work will require on any shift Have you ever had a work related injury or illness. 17. Have you ever had: a) needlestick/blood or body fluid exposure... b) rash or symptoms related to glove use... I certify that the information documented above is true and complete. I understand that misrepresentation or omission of facts called for may prevent or result in termination of medical staff privileges if granted. To the best of my knowledge, I do not have any physical or mental health impairment which is of potential risk to patients or that might interfere with the performance of my duties, including habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs (including those prescribed) which may adversely alter my behavior or judgement. Printed name of Medical Professional Applicant: Signature of Medical Professional Applicant: Health care provider s summary and elaboration of all pertinent data. Please comment on all positive answers. Health Care Provider: Date: Req Med Clearance Page 4 of 5 Rev. 4/2008

5 Documentation of Physical Examination Name: Date of Exam: BP: / Temp: Pulse: Respiration: Weight: Height: Examination: (Must be within 6 months of application) rmal Abnormal NE tes: Describe abnormality with pertinent numeral before comment. 1. General Appearance 2. Skin 3. Head 4. Eyes 5. Ophthalmoscopic 6. Ears 7. se 8. Mouth/throat 9. Neck/thyroid 10. Lymphatics 11. Breasts 12. Thorax/lungs 13. Heart 14. Abdomen 15. Vascular system 16. Extremities/feet 17. Spine 18. Musculoskeletal 19. Neurologic 20. Psychiatric Diagnosis and assessment of medical problems: Medical Problems Ongoing medical problems: (Explain) Limitations/Recommendations: (Further specialist examinations, labwork, x-ray, immunizations, etc.) Limitations Limitations: (Explain) After examination as required and to the best of my knowledge, I have determined that this individual is free from any health impairment that is of potential risk to patients or which might interfere with the performance of his/her duties. This included the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances, which may alter the individual s behavior or judgement. Printed Name of Physician/Health Care Provider: Date: Physician/Health Care Provider Signature: Physician/Health Care Provider Address: Telephone: ( ) Req Med Clearance Page 5 of 5 Rev. 4/2008

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