Page 1 of 6 NEW TEACHER/TEACHING ASSISTANT PHYSICAL EXAM PACKET Dear Teacher/Assistant: Physical exams performed by a licensed provider are required by Head Start Performance Standards Region 7 ESC Head Start requires that the physical exams be completed within 30 days. Please read the instructions in this packet carefully and follow the directions completely. When you have completed all of the steps for the physical, return all necessary forms to the person noted in the instructions.
Page 2 of 6 Checklist for Teacher/Teaching Assistant Physicals Make an appointment with one of the providers (physicians) listed on page 3. These are the ONLY providers (physicians) that you may choose from in order for Head Start to pay for the physical exam and TB screening/test. Immediately after contacting the provider and scheduling an appointment for a physical (the same day), contact Aletha Gandy at the number listed on page 3. Aletha must have at least 5 days advance notice of the appointment in order to process the paperwork for the physical exam. Complete the TB Questionnaire on page 4 before your appointment and hand it to your provider (physician) when you go to the office for your appointment. Take the entire New Teacher/Assistant Physical Packet with you to your visit to the provider/physician. After your provider (physician) reviews the TB Questionnaire, he/she will make the determination as to whether or not you need a TB skin test based upon your TB Questionnaire. You may or may not have a TB test when you have your physical exam. If you do have a TB test with your physical exam, it is your responsibility to return to your provider as he/she has directed to have the TB skin test results read. The TB test is not complete unless the final reading is performed. When all components of your physical are complete (your signed physical exam, your completed TB Questionnaire, and, if ordered, a TB test, administered and completed), please mail/fax them to Aletha Gandy at the address on Page 3.
Page 3 of 6 15/16 PROVIDERS FOR HEAD START PAY TEACHER PHYSICALS In order for Head Start to pay for the physical exam, the teacher/aide must: Choose a provider from the list below Make an appointment (Hepatitis B Immunizations are given by Good Shepherd Family Health Clinics and Cherokee County Health Department only) Contact Aletha Gandy (903-988-6831) agandy@esc7.net with the appointment (day-time-provider) Aletha must have 5 business days notice prior to the appointment so she can send required paperwork to the provider Mail or scan a copy of the completed physical (including TB Test information) within 5 business days to: Aletha Gandy Region 7 ESC 1909 N. Longview St. Kilgore TX 75662 SERVICE PROVIDER ADDRESS PHONE Cherokee County Health 510 E. Commerce 903-586-6191 Department (Hepatitis B Immunization only No Physicals) Jacksonville 75766 Longview Wellness Center 1107 W. Marshall Ave, 903-758-2610 Longview (Locations at Gilmer, Kilgore and Longview) East Texas Family Medicine, PA 4201 S. Loop 256, Palestine 903-723-8533 75801 East Texas Medical Center 5875 So. State Hwy. 37, 903-569-6124 Mineola Mineola Cedar Creek Clinic 2418 W. Main St., Gun Barrel 903-713-2000 City 75156 Practitioners on the Go Rhonda G. 3312 N. University Dr., Suite 936-205-1099 Schmidt H, Nacogdoches 75965 Willow Wellness Center, PA 820 E. Front Street, Tyler 903-596-8400 ETMC First Physicians Tyler 75702 6210 S. Broadway, Tyler 75711 903-579-2710 (Contact Anna Gregory) W-F appointments 8:00 4:00
Page 4 of 6 TB QUESTIONAIRE Name of Teacher/Teaching Assistant: School _ Organization administering questionnaire: Region 7 ESC Head Start Date of Physical Exam: Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by the child. Adults who have active TB disease usually have many of the following symptoms: cough for more than two weeks duration, loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats. A person can have TB germs in his or her body but not have active TB. Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if you have been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis. The skin test is not a vaccination against TB. We need your help to find out if you have been exposed to tuberculosis. Please answer the following questions by placing a check in the appropriate box TB can cause a fever of long duration, an unexplained weight loss, a bad cough that lasts longer than two weeks, or coughing up of blood. 1. Have you been around anyone with any of these symptoms? 2. Have you had any of these symptoms of problems? 3. Have you been around who is sick with TB? 4. Were you born in Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe, or Asia? 5. Have you traveled in the past year to Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe, or Asia for longer than 3 weeks? If so, which country? 6. To your knowledge, have you spent time (longer than 3 weeks) with anyone who is/has been an intravenous (IV) drug user, HIV-infected, in jail or prison or has recently come to the United States from another country? 7. Have you ever been tested for TB before? If yes, when? 8. Have you ever had a positive TB skin test before? If yes, when? Yes No Don t Know HS/EHS Teacher/Teaching Assistant Signature (Below is for healthcare provider use only) ************************************************************************************************** PPD administered Yes _ No_ If yes, date administered / / Date read / / Result of PPD test mm response Provider name Provider signature Provider phone number _City _County If positive, referral to healthcare provider Yes No If yes, name of provider Adapted from DSHS EF12-11494 TB Questionnaire for Adults by Region 7 ESC (Rev. 10/13)
Page 5 of 6 Dear Healthcare Provider, You are providing a physical examination on a Teacher/Teaching Assistant who will be working in a Head Start/Early Head Start Classroom. Head Start Performance Standards require that all employees in direct contact with children in the program receive a physical examination that includes a screening for TB. The teacher/assistant should have already completed their portion of the paperwork. If, after review of their responses and your physical assessment, you are of the professional opinion that a TB skin test (or X-Ray) is warranted, please perform the test. Ask the teacher/assistant to return to your clinic for reading of the TB test. If you are of the opinion that a TB skin test is not necessary, do not perform the TB skin test. Please complete the documentation and return the paperwork with the teacher/assistant or mail/fax the paperwork to our office. In review; 1. Review the patient s responses of the TB Questionnaire 2. Complete the bottom of the TB Questionnaire 3. Complete the New/Early Head Start Medical Care Report 4. If a TB test is performed, ask the patient to return for assessment 5. Return all forms to our office (or allow the patient to return the forms) Please contact our office if you have any questions. Thank you, Katie Burnett, RN, BSN Health Coordinator Region 7 ESC Head Start 1909 N. Longview St. Kilgore, Texas 75662 (903) 988-6862 Fax (903) 988-6945 Grantee and delegate agencies must assure that each staff member has an initial health examination (that includes screening for tuberculosis) and a periodic re-examination (as recommended by their health care provider or as mandated by State, Tribal, or local laws) so as to assure that they do not, because of communicable diseases, pose a significant risk to the health or safety of others in the Early Head Start or Head Start program that cannot be eliminated or reduced by reasonable accommodation. HSPS 1304.52(k)(1)
Page 6 of 6 NEW EARLY/HEAD START MEDICAL CARE REPORT CONFIDENTIAL INFORMATION After your physician completes this form, return to Aletha Gandy by scan or e-mail at agandy@esc7.net Or mail to 1909 N. Longview Street, Kilgore, Texas 75662 PURPOSE OF HEAD START EMPLOYEE PHYSICAL EXAMINATION Head Start Performance Standard 1304.52(j)(1) states that Region 7 ESC Head Start must assure that each [Head Start] staff member has an initial health examination (that includes screening for tuberculosis) and a periodic re-examination so as to assure that they do not, because of communicable diseases, pose a significant risk to the health or safety of others in the Head Start program that cannot be eliminated or reduced by reasonable accommodation. Physician Name, Address and Phone or Stamp: Name of Teacher/Teacher Assistant: ISD/Campus: Position: Email: Results of exam: BP Pulse Respiration Temperature Appears to be in good health Is free of communicable diseases and does not pose a significant risk to the health or safety of others in the Head Start program that cannot be eliminated or reduced by reasonable accommodation TB Questionnaire is negative (attached) TB Test Date given TB Skin Test is negative Date read TB Questionnaire indicates possible risk (attached) N/A TB Skin Test is positive, refer to Health Department on (date) Recommend visit with Primary Care Physician regarding PHYSICIAN STATEMENT I, the undersigned licensed physician, pursuant to the Head Start Performance Standard 1304.52(j)(1) as written above, have performed a physical examination. If the Head Start employee does, in my opinion, pose a significant health or safety risk to the Head Start program, a detailed explanation is provided in the space below my signature. Printed Name of Health Care Provider: Date: Signature of Health Care Provider: Comments: Created: 08/01/01 Reviewed: 07/15/2015 Revised: 07/15/2015