PRE-EMPLOYMENT HEALTH PACKET

BHSF 6321 Rev. 4/10/20

PRE-EMPLOYMENTHEALTH PACKET

1BHSF #6155 Rev. 4/10/20

PRE-EMPLOYMENT INFORMATION SHEET

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

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

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

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

Start Date: ______ / ______ / ________ Job Title: ________________________ Department: _____________________

ALLERGIES: __________________________________________________________ LATEX allergy: G Yes G No

Primary Care Physician (PCP):___________________________________________________________________________

Allergist / Specialist: ___________________________________________________________________________________

Current MEDs: ________________________________________________________________________________________

Latex:________________________________________________________________________________________________

Drug Screen Date: _________________ G Neg G Pos C.O. Breath Test: G Neg G Pos

Medical Marijuana Card: G Yes G No Urine Nicotine: G Neg G Pos

DATE of Physical: _______ / ________ / ____________

Location: Please G (1) Box G Baptist G Bethesda East G Bethesda West G BHMG G BOS / BHE G Boca Raton G BocaCare G Corporate G Doctors G Fishermen’s G Homestead G Mariners G MCI G South MIami G West Kendall

P

Examiner Signature:_____________________________________________

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

___/___/___ Mask _______ Size _______ Test / Check ___/___/___ Mask _______ Size _______ Test / Check

QUANTIFERON DATE / / q Neg q Pos

2BHSF #6148 Rev. 12/31/19

OCCUPATIONAL HEALTH SERVICES

VITALS AND VISION SHEET

Name: ________________________________________________________________________ Date: ________________

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

DO NOT WRITE BELOW THIS SECTION - FOR OCCUPATIONAL 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

1

2

3

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8

9

10

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Examiner Signature: ________________________________________________ G PASS G FAIL

3Page 1 of 6 •

health history & screening - statement

name: __________________________________________________ Date: ___________________________________

DoB: __________________________________________ last 4 Digits of social security #: XXX - XX - ___________

Welcome to BaPtist health.

Occupational 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 Occupational Health Services to perform any physical and/or laboratory examination,

whichisnecessarytoverifytheabsenceofcommunicablediseaseoranycondition,which

mightimpairtheperformanceofmydutiesasanemployeeofBAPTISTHEALTH.

________ (Initials)

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

health assessment. _______ (Initials)

5) IherebyaffirmthattheinformationIprovideinthisHealthHistory&Screeningistrueand

correct. _____ (Initials)

ExaminerInitials:_____________

BHSF #6151 Rev. 4/10/20

4

health history & screening

name: __________________________________________________ Date: ___________________________________

DoB: __________________________________________ last 4 Digits of social security #: XXX - XX - ___________history1. Haveyoueverhadmiddleorlowbackpain,conditionorInjury(thoracicorlumbarspine)?G No GYESYear: ________

Listconditionorinjury: ________________________________________________________________________________________

Describeincidents: __________________________________________________________________________________________

__________________________________________________________________________________________________________

Didyouconsultwithoneormoremedicalprovidersregardingyourbackpain,conditionorinjury?G No GYES

MedicalProvider’sname: ______________________________________ Specialty: ___________________________________

MedicalProvider’sname: ______________________________________ Specialty: ___________________________________

Describetypeoftreatment: ____________________________________________________________________________________

DidyouhaveanX-RAY,MRI,and/orCT? ________________________________________________________________________

Haveyoueverhadlowbacksurgery? ___________________________________________________________________________

2. Haveyoueverhadneckpain,conditionorinjury(cervicalspine)?G No GYESYear: ___________________________

Listconditionorinjury: ________________________________________________________________________________________

Describethispain,conditionorinjury,includingitslocationandseverity: ________________________________________________

__________________________________________________________________________________________________________

Didyouconsultwithamedicalproviderregardingyourneckpain,conditionorinjury?G No GYESYear: ____________

Physician’sname: ____________________________________________ Specialty: ___________________________________

Describetypeoftreatment: ____________________________________________________________________________________

DidyouhaveanyX-RAY,MRI,and/orCT? _______________________________________________________________________

Previousnecksurgery? _______________________________________________________________________________________

3. Doyoustillsuffereffectsfromthebackand/orneckproblemdescribedabove?G No GYES

4. Ifso,checksymptomsandseverity(1-10)youcontinuetoexperienceattime:1=MILD-10=SEVERE

G_____Weakness G_____Tingling G _____ Dizziness G _____ Numbness

G _____ Headache G _____ Soreness after lifting G_____Painwithlifting G_____PainwithCoughing

5. Doyoutakeanymedicationsforyourbackand/orneckcondition?G No GYES

ListofMedications: ___________________________________________ Howoftentaken: ______________________________

6. Haveyouevertreatedwithaphysiatrist,painmanagementoranesthesiologistforpainorproblemsintheneck,and/ormiddleorlowback? G No GYES

7. Haveyoueverreceivedchiropractictreatmentand/orchiropracticadjustmentsforpainorproblemsintheneck,and/ormiddleorlowback? G No GYES

8. DoyouhavetroubleperformingtheActivitiesofDailyLiving?G No GYES

Describelimitations: _________________________________________________________________________________________

9. Haveyoueverbeenunabletoworkbecauseofneckand/orbackpain,conditionorinjury?G No GYES

ExaminerComment: _____________________________________________________________________________________________

ExaminerInitials:________________ Employee/ApplicantInitials:________________

Page 2 of 6 • BHSF #6151 Rev. 4/10/20

5

health history & screening (continueD)

yes no DoYouHAVEoRHADTHEfoLLoWIng:resPiratory conDition(s): applicant’s comment examiner’s comment

1. Asthma

2. Emphysema

3. Bronchitis

4. Smoker?/HowLong?

5. Tuberculosis

6. Exposuretotoxicsubstance

7. Exposuretochemicalfumes

8. Other

carDac conDition(s):1. High Blood Pressure

2. HeartCondition

3. CongestiveHeartfailure(CHf)

4. Open Heart Surgery

5. HeartAttack

6. ChestPain

7. Other

neuro/muscular, skeletal & joint conDition(s)1. LeftHand/Wristpain,Injury/condition;CarpalTunnel

2. RightHand/Wristpain,Injury/condition;CarpalTunnel

3. Shoulder/Elbowpain,Injuryorcondition

4. LowBackpain,sprain,injuryorcondition

5. Thoracicspinepain,sprain,injuryorcondition

6. Back-HerniatedIntervertebralDisc

7. Back-SurgicalProcedure

8. BrokenBones

9. Kneepain,injuryorcondition

10. Anklepain,injuryorcondition

11. Legpain,injuryorcondition

12. Hippain,disorder,injuryorcondition

13. footpain,problem,injuryorcondition

14. Amputationoffoot/Leg/Arm/Hand

15. neck/Cervicalspinepain,sprain,injuryorcondition

16. Orthopedic surgery

17. Poliomyelitis – Residual Disability

18. Arthritis/gout

19. Osteoarthritis

20. Arm/forarmpain,injuryorcondition

21. Sciatica

22. SacraldisorderorTailbonepain/problem

23. Osteoporosis

24. Osteopenia

24. RheumatologicalproblemieLupus,RheumatoidArthritis

26. Fibromyalgia

27. Other

comments: Please include medical records related to any musculo-skeletal injury or conditions and any testing (x-ray, ct, mri, etc.)______________________________________________________________________________________________________________

______________________________________________________________________________________________________________


name: ________________________________________________

Page 3 of 6 • BHSF #6151 Rev. 4/10/20

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yes noDoYouHAVEoRHADTHE

foLLoWIng:aBDominal conDition(s):

applicant’s comment examiner’s comment

1. Stomach and/or Intestinal disorder

2. IrritableBowelSyndrome

3. Colitis

4. Crohns

5. gallBladder

6. Ulcer

7. Kidney Disease

8. Hernia

9. Hepatitis

10. LiverDisease

11. Other

meDical conDition(s):

1. Diabetes

2. Epilepsy/SeizureDisorder

3. Headaches / Migraines

4. HeadInjury

5. VascularDisorder

6. Stroke(CVA)

7. Thrombophlebitis(Bloodclot)

8. Anemia

9. Circulatoryproblems

10. Bleeding disorder

11. Cancer

12. Immunosuppressive condition

13. urologicalCondition(Incontinence)

14. Neurological Disorder(neuropathy, leg numbness, Upper extremity numbness

other:

1. Deafness–total or partial hearing loss

2. EarCondition

3. EyeCondition

4. Totalorpartiallossofsight

5. ColorBlind(ColorDeficiency)

6. Dermatitis,SkinRash,Eczema

Past history:

1.

Areyoucurrentlyorhaveyoueverbeenunder the supervision of IPN, PRN, or theDepartmentofHealth?Ifyes,pleaseexplain circumstances, including dates.

Women only:

1.Areyoupregnant?IfYES;Estimateddatedue:______________

name: ________________________________________________


Page 4 of 6 • BHSF #6151 Rev. 4/10/20

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name: ________________________________________________

list all: Examiner Comments

SurgicalProcedures: ____________________________________________________ _____________________________________

__________________________________________________________________ _____________________________________

CarAccidents: _________________________________________________________ _____________________________________

__________________________________________________________________ _____________________________________

otherAccidents: ______________________________________________________ _____________________________________

__________________________________________________________________ _____________________________________

AnyotherIllnessorConditionnotlisted? ____________________________________________________________________________

Please note: Baptist health south Florida requires copies of medical records and work releases resulting from any workman’s compensation, auto or any other accident claim.

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

Date injury company state

DidyoufilealawsuitagainstyouremployerinanyWorkers’Compensationcase? G No GYES

Canyouperformtheessentialfunctionsofyourposition? G No GYES

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.

Page 5 of 6 • BHSF #6151 Rev. 4/10/20

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aDa accommoDations:

1) Ihavereceived,read,andunderstandmyjobdescriptionaswellastheessentialfunctionsofthejob; G No GYES

2) Canyouperformtheessentialfunctionsofthejobwithorwithoutanaccommodation? G No GYES(describebelow)

____________________________________________________________________________________________

____________________________________________________________________________________________

3)Haveyoueverbeenunabletoworkbecauseofanillness,injury,ormedicalcondition? G NO GYES(describebelow)

____________________________________________________________________________________________

____________________________________________________________________________________________

4)Doyouneedanyaccommodation(s)toperformtheessentialfunctionsofthisjob? G NO GYES

comments: _______________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

GMandatoryInfluenzaReviewed HealthProviderInitials:_________

i certiFy that this health history is true anD comPlete anD that i Do not haVe any illness, injury or meDical conDition 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 reQuesteD in this Form 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. 4/10/20

9Page 1 of 2 Form # 6109 Rev. 12/31/19

OCCUPATIONAL HEALTH SERVICESCONSENT to DRUG & ALCOHOL SCREENING

ANDRELEASE of BAPTIST HEALTH SOUTH FLORIDA

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

Statement of Policy

Baptist Health South Florida is committed to creating and maintaining a workplace free of substance abuse. To that end, Baptist Health has developed a policy regarding the illegal use of drugs and the abuse of alcohol or prescription drugs that we believe best serves the interests of all employees. The illegal use of drugs or abuse of alcohol or prescription drugs will not be tolerated. It is a violation of the Baptist Health South Florida Drug-Free Workplace Policy for any applicant or employee to: 1) use, possess, sell, trade, offer for sale, or offer to buy illegal drugs or otherwise engage in the illegal use of drugs on the job; 2) to report to work under the influence of illegal drugs or alcohol; and 3) to use prescription drugs illegally. However, nothing in this policy precludes the appropriate use of legally prescribed medications. Employees are advised that the following are unacceptable explanations for a positive confirmed test result and will be rejected by the MRO: 1) expired prescriptions (i.e. prescriptions which are older than one (1) year from the date of the prescription and are unaccompanied by documentation from prescribing physician indicating continued supervised use); 2) prescriptions which are written for anyone other than the employee; 3) over-the counter herbal supplements containing undisclosed controlled substances for which the employee does not have a valid prescription; or 4) over-the-counter controlled substances purchased in a foreign country.

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

Conditions of Employment

All job applicants and employees must execute this consent and release and must comply with the testing procedures of Baptist Health South Florida before they will be considered for employment. Applicants who refuse to execute this consent will not be considered for employment by Baptist Health South Florida. Employees who refuse to execute this consent may be subject to termination. No guarantee is made that an applicant who passes the tests will be hired. Applicants or employees who test positive for drugs or alcohol may be denied employment or subject to disciplinary action, up to and including termination.

Confidentiality

All information, interviews, reports, statements, memoranda, and drug test results, written or otherwise, received or produced as a result of Baptist Health South Florida’s drug-testing program are confidential and will be maintained in the employee’s Occupational Health Services file. Baptist Health South Florida will not release any information concerning drug test results without a written consent form signed voluntarily by the person tested, unless such release is compelled by an administrative law judge, a hearing officer, or a court of competent jurisdiction pursuant to an appeal taken under Drug-Free Workplace Act (F.S. §440.102) or is deemed 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

I understand and acknowledge that, if I am a Licensed Healthcare Practitioners, (any person licensed under chapter 457; chapter 458; chapter 459; chapter 460; chapter 461; chapter 462; chapter 463; chapter 464; chapter 465; chapter 466; chapter 467; part I, part II, part III, part V, part X, part XIII, or part XIV of chapter 468; chapter 478; chapter 480; part III or part IV of chapter 483; chapter 484; chapter 486; chapter 490; or chapter 491, Florida Statutes), I shall execute, prior to drug testing, a Consent For Release of Drug & Alcohol Screening Results. The purpose of this disclosure is so that Baptist Health South Florida and I may fulfill our legal and ethical obligations pursuant to Florida Statutes Chapters 456 and 464 to report licensees who are in violation of these acts. This Consent for Release of Drug & Alcohol Screening Results authorizes Baptist Health South Florida to release the results of drug & alcohol testing only to the following agencies: 1) the Florida Department of Health; 2) the Intervention Project for Nurses (“IPN”); and/or 3) the Professionals Resource Network (“PRN”); or 4) as may be required pursuant to Florida Statutes §440.102. This consent will be in effect from the date of execution of the Consent for Release of Drug & Alcohol Screening Results until the latter of the following: 1) the successful completion of an IPN or PRN program; 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.

I agree that Baptist Health South Florida may collect the specimens for these tests and may forward them to a licensed or certified laboratory designated by Baptist Health South Florida for analysis. I further agree to 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 subject me to disciplinary action, up to and including termination of employment.

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 release Baptist Health South Florida and its trustees, officers, employees and agents from any and all claims, liabilities and causes of action of any nature whatsoever in connection with a) this consent, b) the performing of drug and alcohol test in connection therewith and c) my not being employed by Baptist Health South Florida if, in the sole opinion of Baptist Health South Florida, I fail to meet any of the requirements established by Baptist Health South Florida in connection with such tests.

I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent 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. 12/31/19

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Occupational 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. Have you ever had any of the following conditions?

a. Seizures(fits): G Yes G No

b. Diabetes(sugardisease): G Yes G No

c. Allergic reactions that interfere with your breathing: G Yes G No

d. Claustrophobia(fearorclosedinplaces) G Yes G No

e. Trouble smelling odors: G Yes G No

3. Have you ever had any of the following pulmonary or lung conditions?

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(collapsedlung): G Yes G No

i. Lung cancer: G Yes G No

j. Broken ribs: G Yes G No

k. Any chest injuries or surgeries: G Yes G No

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

Page1of2•BHSF6126Rev.4/10/20

Today’s Date: ___________________

Name: _______________________________________________________________________ Emp. ID#: ______________________

Job Title: __________________________________________________________ Last4digitsofEmp.SS#: ______________________

Sex(Checkone):GMale/GFemaleD.O.B.:________________________Height:______ft.______in.Weight:____________lbs

T Aphonenumber(includingareacode)whereyoucanbereachedbythehealthcareprofessionalwhoreviewsthis questionnaire:

______________________________________________________________________________________________________

T Whatisthebesttimetophoneyouatthisnumber:_____________________________________________________________

Has your supervisor told you how to contact the health care professional who will review this questionnaire

(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): _________________________________________________________________________________________

___________________________________________________________________________________________________________

12

MEDICAL QUESTIONNAIRE FOR RESPIRATOR USERS continued . . . 4. Doyoucurrentlyhaveanyofthefollowingsymptoms? a. Shortness of breath: G Yes G No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline? G Yes G No c. Shortness of breath when walking with other people at an ordinary pace on level ground: G Yes G No d. Have to stop for breath when walking at your own pace on level ground: G Yes G No e. Shortness of breath when washing or dressing yourself: G Yes G No f. Shortness of breath that interferes with your job: G Yes G No g. Coughingthatproducesphlegm(thicksputum): G Yes G No h. Coughing that wakes you early in the morning: G Yes G No i. Coughing that occurs mostly when you are lying down: G Yes G No j. Coughing up blood in the last month: G Yes G No k. Wheezing: G Yes G No l. Wheezingthatinterfereswithyourjob: G Yes G No m. Chest pain when you breathe deeply: G Yes G No n. Any other symptoms that you think may be related to lung problems: G Yes G No

5. Have you ever had any of the following cardiovascular or heart condition? 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. Heartarrhythmia(heartbeatingirregularly): G Yes G No g. High blood pressure: G Yes G No h. Any other heart condition that you’ve been told about: G Yes G No

6. Haveyoueverhadanyofthefollowingsymptoms? a. Frequentpainortightnessinyourchest: G Yes G No b. Pain or tightness in your chest during physical activity: G Yes G No c. Pain or tightness in your chest that interferes with your job: G Yes G No d. In the past two years, have you noticed your heart skipping or missing a beat: 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. Do you currently take medication for any of the following medical conditions? 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. If you’ve used a respirator, have you ever had any of the following problems when using a respirator?

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. General weakness or fatigue: G Yes G No e. Any other problem that interferes with your use of a respirator: 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 Occupational Health.

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

MedicallyclearedbyOccupationalHealthtowearPFR-N95: ___________________________________________ _______________ Print Name Date

___________________________________________ _______________ Signature Time

Page2of2•BHSF6126Rev.4/10/20

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CONSENT TO POST-OFFER PRE-EMPLOYMENT PHYSICAL EXAM

I, _________________________________, acknowledge that I have received a job offer from Baptist Health South Florida, and that this job offer is conditioned upon, among other preconditions, my submission to a post-offer pre-employment physical exam. I hereby consent to this physical exam, including but not limited to health screening for illnesses/diseases/impairments/conditions, general physical and mental health, and prior accident/injury history, blood test for vaccine titers, tuberculosis screening via Quantiferon or T-spot blood test, latex allergy screening, administration of required vaccines, respirator fit testing, and/or imaging/radiology examination and any other tests deemed necessary. All records related to the pre-employment physical, including any lab/screening/diagnostic results, are securely maintained in the Occupational Health electronic medical record that is only accessed by designated Occupational Health staff. Occupational Health utilizes the Baptist Health Laboratory and Imaging departments to process all pre-employment labs (i.e.: blood titers and Quantiferon blood test) and/or diagnostics tests (i.e.: chest x-ray or other applicable imaging test) administered as part of the pre-employment physical exam. All lab and imaging results performed in Baptist Health departments will be maintained in the Baptist Health South Florida electronic clinical documentation system.

____________________________________________ XXX - XX - ____________Print Name Last 4 digits of Social Security Number

____________________________________________ _____________________Applicant Signature Date

____________________________________________Print Name and Title of Witness

____________________________________________ _____________________Witness Signature Date

THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008“The Genetic information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s or family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services”.

BHSF 6524 Rev. 4/10/20

Occupational Health ServicesPre-Employment Occupational Health Office

BHSF 6202 Rev. 4/10/2013025Y6202

*13025Y6202*

PRE-EMPLOYMENT HEPATITIS-B IMMUNIZATION INFORMATION

Job Location: Please R (1) Box

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 Occupational 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: _________________

G Baptist G Bethesda East G Bethesda West G BHMG G BOS / BHE G Boca Raton G BocaCareG Corporate G Doctors G Fishermen’s G Homestead G Mariners G MCI G South MIami G West Kendall

14

15

BHSF 6203 Rev. 1/16/2011500Y6203

*11500Y6203*

PRE-EMPLOYMENTPARTICULATE FILTER RESPIRATOR INFORMATION SHEET

Job Location: Please R (1) Box

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 Occupational Health Nurse.

Applicant / Employee Signature: _________________________________ Date: _________________

Witness Signature: ____________________________________________ Date: _________________

G Baptist G Bethesda East G Bethesda West G BHMG G BOS / BHE G Boca Raton G BocaCareG Corporate G Doctors G Fishermen’s G Homestead G Mariners G MCI G South MIami G West Kendall

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N-95 PARTICULATE FILTERRESPIRATOR MASK (N-95 PFR)

G I wear a size: __________________ N-95 PARTICULATE FILTER RESPIRATOR MASK (N-95 PFR)

G I understand that I must fit check the seal of the N-95 respirator mask prior to each use. To place the N-95 PFR respirator mask properly on my face one strap is to be placed above the ear and the other strap goes below the ear and the mask is then molded to my face.

G I understand that a fit check is performed by taking a deep breath in and then exhaling rapidly through my mouth. If air is felt escaping from around the seal, the mask is readjusted and the same procedure is repeated until a seal has been established. This is to be done each time I place the N-95 PFR respirator mask on.

G I understand I am required to wear the N-95 PFR respirator mask for my protection when caring for patients who are on Airbourne isolation or when assisting / performing High Risk procedures (endotracheal suctioning / bronchoscopy) in patients suspected of having Tuberculosis.

G I understand if I lose or gain weight, have facial surgery, dental work or any procedure that alters the shape of my face and I am unable to successfully complete a fit check, I will go to Occupational Health Services to be re-fit tested.

G I understand that if I have any facial hair or beard that prevents direct contact between my face and the N-95 PFR respirator mask I can not wear the mask.

G I will not knowingly allow another employee, who has not been fit tested, into an Airborne Isolation room. I will instead instruct them to be fit tested in Occupational Health Services. I understand that neither the patient nor family members are to wear the N-95 PFR respirator mask.

G I understand that if an Airborne isolation patient is transported to another department, the patient is to wear a regular surgical mask and the mask should be changed about every 20 minutes to prevent aerosolization.

G I understand that when the patient on Airborne Isolation goes outside the isolation room and wears a regular tie surgical mask there is no need for me to wear the N-95 PFR respirator mask. If the AFB isolation patient is not wearing the mask I am to wear the N-95 PFR respirator mask.

G The N-95 PFR respirator is to be appropriately discarded after one entrance into isolation room.

G I understand that should the integrity of the N-95 PFR respirator mask become compromised (becomes soiled, wet or the seal can no longer be maintained) I should dispose of the mask and obtain a new N-95 PFR respirator.

G I understand when disposing of the N-95 PFR respirator it can be placed in the regular trash unless it is saturated with visible blood or body fluids (Then I will place it in the red biomedical trash container).

G I understand that should I experience any chest pain, shortness of breath, light-headedness, diaphoresis, or anxiety while wearing the PFR N-95 Respirator, I am to remove the Respirator ASAP and report the symptoms to the Occupational Health Office. I will not attempt to wear the PFR n-95 mask until my symptoms have been reported to and I have been evaluated by the Occupational Health Office.

G I have read and answered the above questions and have been given an opportunity to ask questions regarding the use of the N-95 PFR respirator mask.

Employee Name: ____________________________________________________________________ Date: __________________

Employee Signature: _________________________________________________________________ Time: _________________

Occupational Health Services Representative’s Name: ______________________________________ Date: __________________

Representative’s Signature: ___________________________________________________________ Time: _________________

Designation: White - Occupational Health, Canary - EmployeeBHSF 6122 Rev. 12/31/19

*11500Y6122**11500Y6122*

17

Carbon Monoxide Testing Consentfor the purpose of determining smoker status

Form #5342 Rev. 4/10/20

The use of a Carbon Monoxide Breath test machine is a widely recognized and highly reliable method of determining smoker status. Occupational Health offers new hires and employees the opportunity to take a Carbon Monoxide Breath test to determine their smoker status. Agreeing to take this voluntary test will help us determinethe rate you will pay per-pay-period on your Baptist Health South Florida medical plan employee contribution. Ifyour results are negative for carbon monoxide and you have no covered adult dependents who use tobacco or vaping products, you will avoid a $50 per-pay-period smoker surcharge. If your results are positive for carbon monoxide and you are not a smoker, you will have the option to take a nicotine urine test to confirm your smokerstatus. You will be subject to a $50 per-pay-period smoker surcharge on your medical plan employee contribtionif you test positive for nicotine. All smokers will be offered a BHSF Wellness Advantage Stop Smoking packet enclosed with information about our Smoking Cessation Programs. Enrolling and completing any of these programs, within the required timeframe, will allow us to update your medical plan status as a non-smoker.

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

By signing this form, I am giving consent to the Occupational Health clinician to conduct a Carbon Monoxide Breath test to determine my smoker status. I understand that my test results will be submitted to WellnessAdvantage for tracking and communicated to the Benefits Department for determining my BHSF medical planemployee contribution.

Employee Signature: _____________________________________________ Date: ____________________

Occupational Health clinician: ______________________________________ Date: ____________________

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

Distribution: White - Occupational Health / Yellow - Candidate

Documents

PRE-EMPLOYMENT HEALTH PACKET