EHS. Employee Health Services. 205 Sunnyview Lane Kalispell, MT (406) FAX (406) A Division of Kalispell Regional Healthcare

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1 EHS Employee Health Services Dear Kalispell Regional Healthcare New Hire: Congratulations on receiving a conditional job offer from Kalispell Regional Healthcare (KRH). This offer is contingent upon successful completion of a drug screen, inquiry about health related issues and jobrelated physical demand testing. Here at KRH we take your safety and the safety of our patients and visitors very seriously. We depend on you to provide correct information. Please answer the following questions completely and accurately. Your pre-employment screening appointment will consist of the following: Mandatory Flu immunization Urine drug test* and blood draw Review of medical and immunization history Review and testing of the physical requirements of the position you have accepted Job required immunizations Your appointment may take up to 3 hours please plan accordingly; make child care arrangements prior to your appointment. You will be performing job related lifting activities along with strength and motion measures. Dress comfortably, or as if you were going to work out at the gym - sweat/exercise pants, t-shirt and tennis shoes. Please bring a government-issued photo ID. Please note, if you have a medical condition that may affect the essential functions of your job, a medical records release may be necessary to gather additional treating medical information. The attached forms must be completed in their entirety and forms should be returned to OHS at least 24 hours prior to your appointment. If you arrive for your screening appointment without all forms completed, your appointment may either be delayed or need to be rescheduled to a later date. Forms may be returned via; FAX (406) to OHSPatientDocuments@krmc.org Dropped off directly to OHS OHS is located within the Summit Medical Fitness Center. Park on the south side of the building on Sunnyview Lane. Enter through the back doors of the Summit. Please go up the stairs, or use the elevator on your left to reach the clinic. OHS is the second door on the right hand side as you come up the stairs. Normal clinic hours are Monday through Friday, 7:30 am to 4:00 pm. We look forward to seeing you. If you have any questions, please feel free to contact Lugene at *NOTE: Please do not consume excessive amounts of liquid prior to your appointment. Doing so may result in a *Dilute* test result and you will then be asked to come back in to provide another specimen. Please try not to urinate just prior to your appointment. 205 Sunnyview Lane Kalispell, MT (406) FAX (406)

2 EHS Employee Health Services PRE-EMPLOYMENT SCREENING INSTRUCTION FOR COMPLETION OF FORMS Please refer to the following instructions when completing: Consent for Evaluation and/or Treatment Receipt of Privacy Practices TB Management Form 1. Consent for Evaluation and/or Treatment Sign and date Signature line and print name. Complete the box at the bottom of the form. A government-issued photo ID is required. 2. Acknowledgement of Receipt of Notice of Privacy Practices Complete: Patient Name Signature Date Signed Please read Reporting of Immunization Records section and complete as indicated, this section applies to all applicants, including a minor child applying for employment. Note: A copy of Privacy Practices is available in the Occupational Health Office for your review. 3. Tuberculosis Management Form Complete first box that contains date; name; DOB, etc. (you may leave Department and Job blank if you are unsure). Complete sections numbered I, II, and III. Sign the form at the bottom of the page, above Employee Signature, and date. 205 Sunnyview Lane Kalispell, MT (406) FAX (406)

3 OHS Occupational Health Services Consent for Evaluation and/or Treatment I am an applicant, new hire, examinee, or the parent/guardian of a minor applicant/new hire/examinee. I consent to the evaluation, testing and/or screening procedures that may be performed by Occupational Health Services ( OHS ) for any of the following: Independent Medical Examination; Impairment Rating; evaluation and treatment of injured patient, Transfer of Care; Disability Examination; and/or in connection with employment; job-specific criteria; and/or determining my functional abilities as related to an injury or condition. I also consent to procedures and/or treatment that may be performed in connection with care provided by OHS. I understand and acknowledge that: The tests may include, but are not limited to, routine diagnostic procedures, physical examination, urine collection for drug testing, review of health history, hearing testing, vision testing, pulmonary, functional evaluation, job-specific activities, respirator fit testing, immunizations, and/or blood draw. Medical information maintained at OHS related to prior contacts with OHS staff will be available for review along with copies of all medical records and current medical information, including information in the EMR. The results of the test(s) may be used for decisions relating to my employment, disciplinary action, or continued employment. There is no doctor/patient relationship established by this examination (unless the appointment is for a transfer of care, or pending transfer of care, with authorization from Workers Compensation). No recording of exams is allowed. At the discretion of the provider, case managers, lawyers, and/or family members may not be allowed in the exam room. I have the ability to terminate the examination at any time. It is my responsibility to inform the examiner of any discomfort or injury I may perceive during the exam in order to prevent exacerbation/injury while under evaluation. Where an employer or insurer has not ordered, authorized, and/or is not financially responsible for the evaluation, I will be responsible for payment of the evaluation. No guarantees have been made regarding the outcome of the evaluation, testing or screening. RELEASE OF INFORMATION I hereby grant OHS authorization to release medical information necessary for the adjudication of all claims relating to care provided, or to the employer requesting employment screening procedures. This information may be released to insurance company(s), governmental programs or medical review organizations. I have read and understand the above. Signature ** THIS AGREFMENT EXPIRES 6 MONTHS FROM DATE OF SIGNATURE Name Printed Date Signature of Witness (OHS Staff Only) Name Printed Date _ Patient Name (Last, First, MI): Mailing Address: Date of Birth: / / SSN: - - Cell Phone: Msg? Y / N Home Phone: Msg? Y / N Results of any drug and/or alcohol testing will be treated confidentially and will not be released to any other person without my specific written consent* except under conditions specified by 49 CFR Part 40 and MCA *In addition to my employer, I request that my test results be released to: ohs file serve/forms/scheduling: clerical forms REV 08/2015 kw 205 Sunnyview Lane Kalispell, MT (406) FAX (406)

4 EHS Employee Health Services Work-Related Immunizations and Communicable Disease Record *Annual Influenza vaccination is a mandatory requirement for employees in all positions at Kalispell Regional Healthcare. Other vaccinations may be mandatory based upon the position for which you are applying. Medical or religious exemptions to vaccinations may be considered upon approval of appropriate documentation. Are you willing to receive immunization(s) or provide appropriate exemption documentation according to Kalispell Regional Healthcare policy and position expectations? Questions regarding Kalispell Regional Healthcare policy may be directed to Human Resources at (406) Questions regarding immunization requirements for specific positions may be directed to Employee Health Services at (406) Please bring documentation of: MMR (measles, mumps, rubella) Record of 2 shots OR Record of Titers TB skin test (PPD-tuberculosis) Record of 2 negative tests from last 2 years OR record of 1 negative test from previous year and 1 negative test from current year. Positive test record of most recent chest x-ray Quantiferon (QFT - blood test ) Varicella (chickenpox) Record of vaccine, titer, or good recall of disease Hepatitis B (series of 3 shots and titer) Required for some positions Documentation of start of series or finished series and titer TDAP/Td (Tetanus, diphtheria, pertussis) TDAP (tetanus, diphtheria, pertussis): record of immunization after age 19 Td (tetanus, diphtheria): record of immunization within the last 10 years Hepatitis A (Recommended for Childcare areas, Environmental Services, Maintenance, Nutrition Services) Current Influenza shot* if received within past year Please note: your position may require one or more of the above-listed immunizations. 205 Sunnyview Lane Kalispell, MT (406) FAX (406)

5 EHS Employee Health Services Tuberculosis Management Form Date: Print Name: DOB: Dept: Job: Are you pregnant? Y N I am a known positive TB I have been tested for TB I: Check if applicable: responder. elsewhere within the last 12 (Complete section V) months (attach documentation). II: Have you had within the last 3 months? Are you taking corticosteroids (like prednisone)? YES NO Are you diabetic? Prolonged productive cough (lasting more than 3 weeks) Bloody sputum Fever/chills None of these III: Particulate Respirator Annual Assessment: Do you wear a respirator? YES NO Night sweats Easily fatigued Weight loss Loss of appetite Are you taking immunosuppresive drugs? YES NO Do you have any immunosuppressive illness? YES NO IV: Tuberculosis Test must be read in OHS hours. NO SELF READING!! PPD 0.1cc 5TU Lot#: Expiration Date: Administered L / R forearm intradermally on: [Date] BY: [Signature] [Print Name]: TB Test Evaluated on: [Date]: Result: mm Pos / Neg (circle one) If >5mm note risk factors: BY: [Signature] [Print Name]: V: Known Positive Responders Complete the Following: Date of first positive skin test: Dates of last two negative chest x-rays: Have you ever taken medication for tuberculosis: YES NO If yes, list date(s) and medication(s): Please initial that you have read and understand the following: I have not had any of the symptoms listed in section II during the past year: If I develop any of the symptoms listed in section II I will contact OHS: I certify that the information contained on this form is correct and complete to the best of my knowledge. Employee signature Date I find this person free from communicable tuberculosis. OHS healthcare provider signature Date 02/10/16 OHWS Exposure 3 month exposure followup Private Pay / Paid 205 Sunnyview Lane Kalispell, MT (406) FAX (406)

6 Pre-Placement Health Assessment Name: Gender: M / F (Last) (First) (MI) Americans With Disabilities Act: Please answer these questions: Yes No 1. Have you reviewed the job summary? 2. Based on your knowledge of the job are accommodations needed to allow you to safely perform the essential functions of the job? If yes please explain: Have you ever worked for Kalispell Regional Healthcare in the past? Yes No When? Have you ever had a work injury or illness? Yes No When? Have you ever been in a motor vehicle accident? Yes No When? Have you ever been discharged or rejected from the Armed Services for a medical reason? If yes, please list: Yes Do you have any allergies? (medications, food, pollens, dust, chemicals, etc.) If yes, please list: Yes No Have you had any surgeries? Please List: Do you or have you had any conditions that may or Never Current Past Comments may not affect: 1. Overall fitness and feeling of wellbeing? 2. Bones/joints/spine? 3. Heart, blood vessels, blood, or bleeding? 4. Muscles, tendons, or ligaments? 5. Eyes or vision? 6. Ears or hearing? 7. Lungs or breathing? 8. Stomach, liver, or bowels? 9. Bladder or kidneys? 10. If applicable to job: (Women) Female organs? 11. If applicable to job: (Men) Male organs? 12. Nervous system? 13. Emotional or mental conditions? 14. Substances? (Alcohol, drugs, etc.) 15. Cancers? 16. Diabetes or thyroid disease? 17. Any procedures? (MRI, CT, EMG/NCS, etc.) 18. Any treatments? (Chiropractic, Physical Therapy, Occupational Therapy, etc.) 19. Any joint or spinal injections? 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 or family member s genetic tests, the fact that an individual or an individual s 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. No

7 Pre-Placement Health Assessment Please explain any conditions listed, including those that are work-related: Please list ALL current medications:. Have you ever come into contact with, or had issues with (please check applicable boxes): Wood Dust Grain Dust Rock Dust Cotton Dust Coal Dust Smoldering Agents Petroleum Products Formaldehyde Latex Ethylene Oxide Disinfectants Glutaraldehyde Asbestos Mercury Anesthetic Gases Methyl Methacrylate Radiation Lead Insulation Materials Hazardous Drugs Cadmium Nitrous Oxide Paint Thinners/Removers Lacquer/Varnish/Enamels Airborne Pathogens (TB,SARS) Silicates Gasoline/Solvents/Acids Insecticides/Herbicides Polychlorinated Biphenyls If you marked any of the products above, please describe contact length and/or issues: READ CAREFULLY BEFORE SIGNING: I certify the answers to the questions on this self-report form are true. I understand that any false statement, misrepresentation, or omission may be cause for dismissal. I understand that Kalispell Regional Healthcare reserves the right to a) refuse employment to individuals who do not complete all or any part of this Medical History Report and b) terminate employees if Kalispell Regional Healthcare becomes aware that this Medical History Report contains any false statements, misrepresentations, or omissions. Employee Signature: Date: Health Care Representative Signature: Date:

8 ACKNOWLEDGMENT OF RECEIPT OF JOINT NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a copy of the Kalispell Regional Healthcare Joint Notice of Privacy Practices. I understand that the Joint Notice of Privacy Practices describes how Kalispell Regional Healthcare may disclose and use my protected health information. Patient Name: Medical Record Number: Signature: Date: Time: If signed by the patient s personal representative, indicate: a. Name of signer: b. Relationship to patient: If acknowledgment is not signed, indicate reason not signed and efforts made to have acknowledgment signed: REPORTING OF IMMUNIZATION RECORDS As described on page 4 of the KRH Joint Notice of Privacy Practices, the Montana Department of Public Health and Human Services (DPHHS) has requested that we seek your consent to share your/your child s immunization data with the DPHHS Immunization Information System (IIS). Therefore, if you do not check the I Opt Out box, below, we will collect and enter your/your child s immunization data into the DPHHS IIS database. DPHHS may release your/your child s IIS immunization data to other public health agencies as well as to your/your child s health care providers to assist in your/your child s medical care and treatment. In addition, DPHHS may release your/your child s IIS immunization data to schools in order to comply with immunization requirements. If you do not check the I Opt Out box at this time, you can always choose to opt out at a later time and/or have your/your child s immunization data removed at any time by contacting your county s health department. You understand that any such revocation will not be effective as to uses and/or disclosures already made in reliance upon this authorization. THIS IS NOT CONSENT TO RECEIVE ANY IMMUNIZATION, IT IS ONLY A CONSENT TO REPORT YOUR/YOUR CHILD S IMMUNIZATION DATA TO THE DPHHS IIS. I OPT OUT OF THE DPHHSS IMMUNIZATION INFORMATION SYSTEM Name of Patient (please print) Date Signature of Patient/Parent, Authorized Representative or Guardian, if applicable A copy of this receipt has been offered to this patient Original Patient s Medical Record Photocopy to Patient KALISPELL REGIONAL HEALTHCARE ACKNOWLEDGMENT OF RECEIPT OF JOINT NOTICE OF PRIVACY PRACTICES /03; 6/09; 8/12; 9/13; 7/14