Welcome to Indiana University Health! We are so glad to hear that you are joining our team. Please schedule to come in to the Employee Health office for your assessment. A health evaluation assessment is required for medical staff membership and/or privileges with IU Health.  Please find the attached forms, along with instructions, and additional information you will need for your visit. Expect your initial visit to be 45 minutes to 75 minutes (if paperwork is not completed). A urine drug screen will be required as part of your assessment. A follow-up visit with Employee health is required 2 – 3 days after the initial visit for a TB read and administration of potential required vaccinations. For your scheduled appointment at IU Health Employee Occupational Health Services, please bring the following required items with you:

1. Photo ID, which may be any of the following: a. Valid driver’s license b. State ID c. Passport

2. Immunization records a. Any and/or all immunizations which should include:

i. Measles, Mumps, Rubella, Hepatitis B, Influenza, TB Testing, Varicella, and TDAP

3. If you wear eyeglasses or contact lenses, wear or bring them for an eye exam 4. Valid credit card (Visa or Mastercard)

Please complete all information requested. The cost of the assessment will be dependent upon records provided. If you are unsure of what to bring/complete or have questions, discuss this with the EOHS staff via phone or when you come for your assessment.

Do not bring children to your appointment.

Please bring your immunization records!

Providers who are not employed by IU Health must have their assessment completed at one of the following locations:

Academic Health Center

Medical Tower, Suite 760 1633 N Capitol Ave Indianapolis, IN 46202 Ph: (317)962-2122 Fax: (317)962-8349 Email: eohs@iuhealth.org Hours: M-F 7:30 am – 3:30 pm

IUH Urgent Care Avon 10853 E US Highway 36 Avon, IN 46123 Ph: (317)779-0606

Bloomington Hospital

Med Arts Building, Suite 107 619 W 1st St Bloomington, IN 47403 Ph: (812)353-9369 Fax: (812)353-5465 Email: screhs@iuhealth.org Hours: M-F 8 am – 4:30 pm IUH Urgent Care Noblesville 14645 Hazel Dell Rd, Suite 120 Noblesville, IN 46062 Ph: (317)922-2090

Concentra Clinic

Clinic locations may be found online at: www.concentra.com

Hours: Mon - Fri 8 am – 8 pm Hours: Mon – Fri 8 am – 8 pm Sat – Sun 8 am – 6 pm Sat – Sun 8 am – 6 pm

Providers who are employed by IU Health may have their assessment completed at any one of the following locations:

ACADEMIC HEALTH CENTER

Adult Academic Health Center Medical Tower MT, Suite 760 Ph: (317)962-8495 Hours: Mon – Fri: 7 am – 3:30 pm

Riley Hospital for Children Riley Outpatient Center – MSA1 Ph: (317)962-2513 Hours: Mon and Fri: 7 am – 12 pm

Morgan Hospital Room 362 Ph: (812)340-7156 Hours: Tues: 9 am – 3:30 pm

EAST CENTRAL REGION

Ball Memorial Hospital Room 7419 Ph: (765)747-3458 Hours: Mon – Fri: 7:30 am – 4 pm

Jay Hospital Jay Medical Facility Ph: (260)766-2782 Hours: Tues and Fri: 7:30 am – 4 pm

INDIANAPOLIS SUBURBAN REGION

North Hospital Room K139 Ph: (317)688-2764 Hours: Mon – Fri: 8 am – 4:30 pm

Tipton Hospital 1000 S Main St Ph: (765)675-1457 Hours: Mon – Fri: 8 am – 4 pm

West Hospital Room C1301 Ph: (317)217-3478 Hours: Mon – Fri: 7 am – 3:30 pm

SOUTH CENTRAL REGION

Bloomington Hospital Med Arts Building, Suite 107 Ph: (812)353-9369 Hours: Mon – Fri: 8 am – 4:30 pm

Bedford Hospital Bedford Occupational Health Clinic Ph: (812)340-7156 Hours: Wed: 8:30 am – 4 pm

Paoli Hospital 642 W Hospital Rd Ph: (812)340-7156 Hours: Thurs: 8:30 am – 4 pm

WEST CENTRAL REGION

Arnett Hospital Room A1275 Ph: (765)838-5842 Hours: Mon – Fri: 8 am – 5 pm

URGENT CARE

IUH Urgent Care Avon 10853 E US Highway 36 Avon, IN 46123 Ph: (317)779-0606 Hours: Mon – Fri: 8 am – 8 pm Sat – Sun: 8 am – 6 pm

IUH Urgent Care Noblesville 14645 Hazel Dell Rd, Suite 120 Noblesville, IN 46062 Ph: (317)922-2090 Hours: Mon – Fri: 8 am – 8 pm Sat – Sun: 8 am – 6 pm

EMPLOYEE OCCUPATIONAL HEALTH SERVICES PRE-PLACEMENT DATA ENTRY FORM

PLEASE PRINT – FILL IN ALL BOXES

Visit Date:

Date of Birth

Cost Center#

PERSONAL INFORMATION

(to complete employee master record)

First Name: Last Name: Middle:

Home Address: City/State/Zipcode

Home Phone – (Area Code & Number): Social Security #:

Job Title: Are you employed by IU Health?

Yes No

HEALTH HISTORY AND ASSESSMENT

SECTION I: DEMOGRAPHIC INFORMATION This form is to help the medical provider assess your ability to perform the essential functions of the job for which you have applied, whether accommodations are appropriate or required, and/or your need for special or emergency medical procedures. Some job classifications may require additional information and examination. This information is CONFIDENTIAL. It will be part of your EOHS medical record. Please Print or Type Name (Last, First, Middle Initial): Birth Date: Place of Birth: Social Security No.:

SECTION II: PERSONAL HEALTH HISTORY

Please List Prescription Medications You Are Currently Taking

NAME DOSAGE WHEN DID YOU START MEDICATION WHY ARE YOU TAKING MEDICATION

MAJOR ILLNESS/INJURIES/SURGERIES

(Indicate if you have ever had broken bones, burns, cuts requiring stitches, etc.)

YEAR DESCRIPTION DOCTOR

KNOWN ALLERGIES [including latex]

ALLERGEN YEAR DESCRIPTION OF REACTION

SECTION II: PERSONAL HEALTH HISTORY

HAVE YOU EVER BEEN DIAGNOSED WITH:

YES NO

AIDS/HIV

Asthma

Back Injury/surgery

Convulsions/Seizures

Depression

Diabetes

Fractures/Bone Injury

Hand Surgery

Hearing Loss

Hepatitis (Type: ______)

YES NO

Nervous Disorders to Anxiety Disorders

Neurological Disorder

Positive TB Skin Test

Rupture (Type: ________________)

Shoulder Surgery

TB (Tuberculosis)

Alcohol or Drug Treatment Program

Foot Pain Frequent Back Pain

Knee Surgery/pain

Lung Disease/Problems

To be completed by Occupational Services Staff:

EYES: VISION (DISTANT) WITHOUT/WITH C. LENS BOTH

(NEAR) WITHOUT/WITH C. LENS BOTH

METHOD OF TESTING: Snellen ___________ Titmus___________ Ishihara: normal ________ abnormal _________

5 Color A 12

B 5

C 26

D 6

E 16

F 0

Health History and Assessment

1. Have you ever: Applied for, or received, Workers’ Compensation Yes No

2. Relative to this job, is there any health related condition for which you require accommodations, i.e., job modification, changes to work area,etc.? Yes No

3. Do you have any restrictions/limitations? Yes No

If you answered yes to any of the above questions, give brief explanation ____________________________________________________

___________________________________________________________________________________________________________________________________

I HEREBY CERTIFY THAT:

1. I have carefully read and completed the foregoing information in the Health Questionnaire and that my answers and explanations are true, tothe best of my knowledge and belief. I understand that falsification of any of the information I have provided herein will be cause fordischarge.

2. I understand that this and other medical information will be held in strict confidence. It will be released only where required by law. Non-confidential information regarding work restrictions relating to job assignment will be provided to management and personnel.

3. I agree to such health assessments by an employee health nurse or company physician as may be required.

4. I acknowledge that I have received a copy of Indiana University Health Occupational Services’ notice of Privacy Practice and understand that I may request aversion of this privacy notice at any time.

_____________________________________________________________________________________________________________________

Signature of patient [legal guardian, if minor]

Health & History reviewed and discussed with candidate

Staff Signature/Date:

__________________________________________________________________________

EMPLOYEE OCCUPATIONAL HEALTH SERVICES

HEPATITIS B VACCINE ACCEPTANCE/DECLINATION

TODAY’S DATE: __________________________________________________

NAME: __________________________________________________

COST CENTER: __________________________________________________

SOCIAL SECURITY NUMBER: __________________________________________________

New federal exposure regulations require hospitals to provide Hepatitis B Vaccine at no cost to employees at

risk of blood / body fluid exposures. Occupational Services has been concerned about Hepatitis B infection

and has provided this vaccine since 1984. This new regulation requires us to show documentation that each

of our employees at risk has either received the Hepatitis B vaccine or understand the risk and decline.

Please complete the following document as it pertains to you.

I accept the Hepatitis B Vaccine Series.

I have already received the Hepatitis B Vaccine Series.

I am currently in the process of receiving the Hepatitis B Vaccine Series.

I understand that, due to my occupational exposure to blood or other potentially infectious materials,

I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to

be vaccinated with the Hepatitis B vaccine at no charge to myself. However, I Decline the Hepatitis

B vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of

acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposures to

blood or other potentially infectious material and I want to be vaccinated with the Hepatitis B

vaccine, I can receive the vaccine at no charge to me.

My job does not put me at risk of exposure to blood/body fluids, and therefore the Hepatitis B

vaccine is not being offered to me at this time. Should my category of risk change in the future, I

understand that I may be eligible.

EMPLOYEE SIGNATURE: ________________________________________________________________

HISTORY Yes No

Any unexplained fever in recent weeks to months?

Any unexplained cough in recent weeks to months?

Any drenching sweats in recent months?

Any unexplained weight loss in recent months?

Any chest pain in recent weeks?

Any known exposure to TB?

If yes, when?

Current or past diagnosis of immune deficiency, sugar diabetes, silicosis, renal failure,

cirrhosis, HIV infection, or been treated with cortisone, methotrexate, cytoxan,

cyclosporine, imuran, prednisone, or chemotherapy (cancer drugs)?

Any major stomach or intestinal surgery?

Any loss of appetite?

Any bloody sputum?

Use of Zantac, Tagamet, Pepcid, Axid or Prilosec, or other prescription medicines to

control stomach acids?

Have you lived outside of the United States, Canada, Australia, New Zealand, or

Northern or Western Europe for longer than 1 month?

Are you currently immunosuppressed or plan to have immunosuppression?

Have you been in close contact with someone who has had infectious TB disease since

your last TB test?

Employee Occupational Health Services Tuberculosis Questionnaire

Name: ____________________________________ EMP ID#: ________________________

Department: _______________________________ Date of Birth: ____________________

Academic Health Center

1633 N Capital Ave, Suite 760

Indianapolis, IN 46202

Bloomington | Bedford | Paoli

PO Box 1149

Bloomington, IN 47403

Arnett | Frankfort | White

5165 McCarty Lane

Lafayette, IN 47905

P: 317.962.8495 F: 317.962.8349 P: 812.353.9369 F: 812.353.5465 P: 765.838.5842 F: 765.838.4771 Email: eohs@iuhealth.org

West

1111 N Ronald Reagan Pkwy

Avon, IN 46123

Email: screhs@iuhealth.org

North

11725 N Illinois Street

Carmel, IN 46032

Ball | Blackford | Jay | Ft. Wayne

2401 W University Ave

Muncie, IN 47303

P: 317.217.3478 F: 317.217.2028 P: 317.688.2764 F: 317.688.2824 P: 765.747.3114 F: 765.751.1322

Email: northaohs@iuhealth.org

If History of Positive PPD

________________ ____________________________________________________ Team Member Signature Date

History of a positive PPD? Yes No

Did you receive BCG? Yes No

When did you first convert to positive TB skin test regarding? ________________________

Did you ever take INH? Yes No If yes, how long? _________________________

Who followed up your conversion? ______________________________________________

When was your last chest x-ray? _________________________ Results? ______________

PRE-PLACEMENT AND TRANSFER CHECKLIST

Your Name _________________________

Job Title _________________________

Please answer yes or no to whether you will be working directly in any of the following areas. What is in ( ) will be

done as part of your assessment.

1. Pharmacy -mixing chemo (CBC and RFT)

YES NO

2. Oncology or chemotherapy -giving chemo (CBC)

3. Plant Operations (Audiogram – Dept Spec)

4. Dishwashers (Audiogram)

5. OR staff (Laser Screening)

working directly with the Laser

6. Repair Lasers (Laser Screening)

7. Homecare patient contact (MD/NP physical)

this is in Home care dept, doing direct care only

8. Animal Lab (animal lab + allergy

Questionnaire, rabies vaccines)

9. Dialysis (HbsAb & HbsAg if not immune)

10. Security Firearms (audiogram)

11. Micro Lab cc#102760 reading micro plates

(Meningitis vaccine)

AUTHORIZATION TO APPLY FOR MEDICAL STAFF APPOINTMENT

Name: _________________________________________________________________________

Social Security #: ____________________________________________#: ____________________________________________

Employee Occupational Health Services:

The above individual wishes to apply for appointment to the medical staff at one or more of our facilities. A health history to include TB, measles, mumps, rubella, hepatitis, varicella, influenza, TDAP, and a drug screen, is required to be considered for appointment. Please verify, by completing the information below, the results of the applicant's health screen, including a drug test.

If you have any questions, please contact the Central Verification Office at (317) 962-8207.

Date Applicant Screened: __________________________: ____________

Location of Appointment: _____________________________________ ______________________________________

□ Applicant has satisfactorily completed all requirements, including a drug screen:

□ Applicant is required to return for a second PPD screen no later than:__________________.

□ Second PPD screen has been waived.

□ Applicant is not eligible for consideration at this time

Comments: ___________________________________________________________________

Verified by authorized Employee Occupational Health Staff:

Signature: _______________________________________________ Date: ________________

Name Printed: ____________________________________________________________________

IT IS THE APPLICANT’S RESPONSIBILITY TO RETURN THIS COMPLETED FORM TO THE IU HEALTH CENTRAL VERIFICATION OFFICE.

PLEASE EMAIL TO: IUHEALTHCVO@IUHEALTH.ORG

Name_______________________________

Dept________________________________

Manager_____________________________

Job Title___________________________ Please Check

Orientation Date____________________ FT PT Supp

Recruiter__________________________

OFFICE USE ONLY

Titers date Results

Rubella _____________ _____________

Rubeola ______________ _____________

Mumps ______________ ______________

Varicella ______________ ______________

MMR 1 ______________ Varivax 1 ______________ Meningoccal 1______________

MMR 2 ______________ Varivax 2______________ Meningoccal 2 ______________

Hep B 1_____________ 2________________ 3 ________________ Surface Ab _____________

Hep B Accept/Decline_______________

Tdap _______________ Flu___________________

PPD 1 Follow up Date______________________ Time_________________________

PPD 2 Due Date ________________________ Tspot date________ Result_______

Pending for Clearance________________________________________________________

__________________________________________________________________________

Staff Name____________________________________

Arrival ________

Start __________

End __________