Volunteer Health Assessment Form PDF

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Volunteer Health Assessment

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Humber River Hospital Volunteer Health Assessment Form Dear Humber River Volunteer, The attached health screening form will need to be taken to your family physician or walk-in clinic for completion. Please start this testing as soon as possible as it must be completed before you can begin volunteering and it does take time to complete. Before submitting your completed Health Assessment Form, please take extra time to ensure you have included all the documents and information required. Incomplete health screening and documentation will delay your volunteer service start date. Please note: any fees related to health screening are the responsibility of the volunteer. If you have any questions or concerns about this document please contact the Humber River Hospital, Occupational Health at 416-242-1000 ext. 82701. Completed Health Assessments forms are to be returned to Volunteer Services.

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Dear Physician, The Public Hospitals Act, Regulation 965, Section 4.1.e, requires that health surveillance and communicable disease surveillance be conducted on ‘all persons carrying on activities in the hospital’, including employees, physicians, nurses, contract workers, students, post-graduate medical trainees, researchers and volunteers. Your patient has applied to be a volunteer at Humber River Hospital. In order to begin their volunteer service, a Health Assessment must be completed PRIOR to commencing any work at the hospital. If possible, please waive any fees associat ed with this testing. If you have any questions or concerns about this document please contact the Humber River Hospital, Occupational Health at 416-242-1000 ext. 82701. Thank you!

Version: May 23, 2017

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SECTION A: Personal Information LAST NAME: PHONE (H): EMAIL ADDRESS:

FIRST NAME: PHONE (C):

MIDDLE INITIAL: DATE OF BIRTH:

I have read and declare the information I have provided on all pages to be accurate to the best of my knowledge. As a volunteer, I am aware that I risk exposure to infectious diseases, and will not hold Humber River Hospital responsible for any adverse effects to myself and/or my family Volunteer SIGNATURE:

DATE:

SECTION B: Personal Vaccination Requirements –As per the Public Hospital Act, all volunteers are required to submit proof to the following through an up-to-date record of immunization OR laboratory evidence of immunity. **Must be signed by a physician. RECORD OF IMMUNIZATION Measles Mumps Rubella Varicella

Date of Dose 1:

Date of Dose 2:

Date of Dose 1:

Date of Dose 2:

LABORATORY EVIDENCE OF IMMUNITY INCLUDING PHL REPORTS Date: Date: Date: Date:

Result: Result: Result: Result:

Hepatitis B - Please Note: The Advisory Committee on Immunization Practices at the Centres for Disease Control and Prevention advises everyone to be vaccinated against Hepatitis B via a three-dose series. RECORD OF IMMUNIZATION Hepatitis B 1.

Date of each Dose: 2. 3.

LABORATORY EVIDENCE OF IMMUNITY INCLUDING PHL REPORTS Date:

Result:

Diphtheria, Tetanus, Acellular Pertussis (Dtap) All individuals who have not received or are unsure if they have received a dose of Dtap should do so as soon as feasible. VACCINATION

DATE GIVEN

CLINICAL NOTE

Influenza Vaccination Annual flu vaccination is the responsibility of and is an expectation for those working at HRH. Please provide documentation if you are medically exempt from influenza vaccination. Date of Last Flu Vaccine: __________________ Bleach Sensitivity Humber River Hospital uses bleach based solutions to clean, disinfect and safeguard our patient environments as part of our infection prevention program. Please identify if you are sensitive to bleach products. ฀ Yes, I am sensitive to bleach. Describe your symptoms:___________________________________________ ฀ No, I am not sensitive to bleach. Version: May 23, 2017

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SECTION C: Tuberculosis Testing Evidence of a baseline two-step TB Skin Test (TST) is required UNLESS:  There is documented results of a prior two-step OR  Documentation of a negative TB Skin Test within the last 12 months, in which case a single-step test may be given (OMA/OHA guidelines 2016)  It is contraindicated for health reasons An annual TB Skin Test thereafter is required. 2 Step Mantoux Test Step 1 Step 2

Date Tested

Date Read

Result (+ or -)

Induration (mm)

1 Step Annual Mantoux Test 1. If your patient is a known positive reactor to TB Skin Testing or has converted to positive, the following is required to be verified by your health care practitioner: a. TB symptom assessment (see below) b. Chest x-ray report within the past twelve months, please attach: Date of Chest X-ray: ________________ Result: ___________ c. Date of last TB Skin Test: Date: ________________ (d & e only to be completed for those who have converted to positive) d. Counselling about treatment of latent TB infection by physician (ie. Prophylaxis): YES [ ] e. Notification of TB status to Local Medical Office of Health (Toronto Public Health): YES [ ] Symptom Blood in sputum with coughing Cough of more than 3 weeks Fever or chills Loss of appetite More tired than usual Night sweats Swollen lymph nodes Weight loss Physician’s Signature:

Yes

NO [ ] NO [ ]

No

Physician’s Stamp

Date:

Version: May 23, 2017...