You are asked to complete this Post-Job Offer Health Screen because you have received a conditional offer of employment for a position with Presbyterian Homes & Services. The purpose of this questionnaire is to determine whether you have any conditions that could affect your ability to perform the position you have been offered. If such a condition is identified, we will work with you to evaluate workplace modifications that may allow you to safely perform the essential functions of the position. Your safety and the safety of our residents and your co-workers is our paramount concern.
Based on your responses, you may be referred for examination by an occupational health physician. You may withdraw from this process at any point, in which case your conditional job offer may be rescinded. The information you provide and the results of any further examination will be kept in a confidential medical file maintained separately from your personnel file.
Please respond “YES” or “NO” to the questions asked. If “YES,” please provide additional information to explain your response. However, please do not disclose any genetic information, such as the results of genetic testing or any family medical history, when responding to these questions because Title II of the Genetic Information Nondiscrimination Act (GINA) prohibits employers from requesting such information.
IT IS IMPORTANT THAT YOU ANSWER EVERY QUESTION. OMISSIONS AND SKIPPED QUESTIONS MAY CAUSE DELAYS IN YOUR HIRING PROCESS. LIKEWISE, YOUR OMISSION OR MISREPRESENTATION OF INFORMATION REQUESTED COULD, UPON DISCOVERY, RESUILT IN THE TERMINATION OF YOUR EMPLOYMENT.
As related specifically to the position you have been conditionally offered, please answer the following questions, each of which states an activity, definition, and examples (not all inclusive) of essential job functions.
Tuberculin and Communicable Disease Assessment
Baseline TB screening at the time of hire is required for all employees post job offer. Baseline TB screening consists of two components: (1) assessing for current symptoms of active TB disease, and (2) testing for the presence of infection with Mycobacterium tuberculosis by administering a single TB blood test.
Complete all sections of the TB symptom assessment below. An Employee Health Nurse will contact you for next steps including completion of a TB Blood test. When contacted by a nurse, it is important that you get the test completed within 24 hours.
All employees must have a negative TB symptom screen (i.e., no symptoms of active TB disease) and a negative TST (blood test result) prior to beginning work.
Hepatitis B Consent/Declination
Employees may benefit from receiving Hepatitis B vaccination by developing immunity from the disease. The risks associated with the vaccinations may include any of the following: soreness; pain; tenderness; itching; redness; bruising; warmth; and lump formation at the injection site or fatigue/weakness; headache; fever; malaise; nausea; diarrhea; pharyngitis and upper respiratory infection. In rare cases, allergic reactions may occur to the vaccine or its components. For that reason, persons who have sensitivity to yeast, vaccine components, or who have had reactions from previous injections should not take the vaccine. Any serious active infection is reason to delay use of the vaccine except by specific order of the employee’s personal physician. Caution should be used when administering the vaccine to persons with severe heart or lung problems or in persons in whom a febrile (fever) or systemic reaction could cause a significant risk. The vaccine should be given to pregnant women only if clearly needed. Caution should be used when administering the vaccine to nursing mothers. This data was taken from studies conducted by the manufacturer of the vaccine.
The vaccine is generally given in 3 doses at one and five month intervals after the initial dose. Upon completion, the employee will be offered laboratory testing to determine the effectiveness of the vaccines. If immunity has not been achieved, one booster vaccination will be given and laboratory testing will be repeated. If immunity is still not established, an additional 2 boosters will be given and laboratory testing will be offered for a third time. Regardless of the outcome of the third testing, Presbyterian Homes & Services will be considered to have met its obligations for the vaccination program. Employees may choose to discontinue the vaccinations at any time but may not have developed immunity. If an employee fails to report for any dose of the series or any of the requested laboratories testing it will be interpreted that the employee wishes to decline further participation in this program. However, the employee will be allowed to resume participation at a later date if desired. Employees are encouraged to consult their personal physician for any questions about the Hepatitis B vaccination program prior to starting the vaccinations. Employees who have started the vaccination series elsewhere but have not completed it will be allowed to finish any missed doses but the series will not be restarted. Presbyterian Homes will not accept responsibility for antibody testing of employees who completed the initial series of vaccinations prior to February 29, 2000.
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 understand that if I would like to be vaccinated with Hepatitis B vaccine at this time that it is my responsibility to contact Employee Health Services to begin the series.
I also understand that I have been given the opportunity to be vaccinated with Hepatitis B vaccine at this time and if I decline this vaccine I still may continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I understand that I may receive the vaccination series at no charge to me by contacting the Employee Health Nurse.
If I choose to accept I understand that an Employee Health Nurse will send me an invitation for the vaccines prior to my start date and that it is my responsibility to contact the Employee Health Nurse within 10 days following my start date to schedule the vaccinations.
Resident Aide Health Screen
Below are examples of the core tasks (essential functions) of a Resident Resident Aide. With this in mind, have you experienced any limitations within the last year that have affected your ability to perform any of the following core tasks?
Question 1: Standing/Walking/Balancing: Remaining on your feet in an upright position with active movement for up to your entire shift.
Question 2: Carrying/Pushing/Pulling/Lifting/Moving: Moving objects by holding or supporting them in your hands, arms, or on your shoulder for long periods of time. Raising, lowering, or moving objects up to 10 pounds from one place to another for up to your entire shift; 11 to 50 pounds for up to 1/3 of the shift.Examples: Supporting an extremity while performing Activities of Daily Living or other for which certification is not required; working with supplies, linens, food, medications & various equipment.
Question 3: Reaching/Bending/Twisting/Turning: Holding arms/hands in one position for extended periods of time, implies a full range of motion above shoulder level and below knee level. Bending the trunk forward or to the sides at the hips for up to your entire shift. Examples:Assisting residents, retrieving supplies, linens and various equipment, making beds, serving food, making beds, cleaning, etc.
Question 4: Squatting: Bending the legs at the knees to come to rest on the knee or knees; maintaining a position in which the body is supported on the feet and knees are bent so that the buttocks rest on or near the heels for up to 2/3 of the shift.Examples: Performing some duties such as working with wheelchair footrests, residents' feet and lower extremities.
Question 5: Fine Motor Skills/Writing: The ability to perceive through the tactile sense. Handling: Seizing, holding, grasping, turning, or otherwise working with the hand or hands. Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arm as in handling) Examples: The ability to write and record data and information with a pen/pencil, keyboard, computer mouse, performing activities of daily living, serving/preparing food, utilizing equipment (e.g. B/P, thermometers etc.)
Question 6: Vision/Color Awareness/Smell: The ability to judge distance and spatial relationships (i.e. location of objects) and to see an area up and down, right and left.
Examples: Seeing call lights or systems, reading vital signs from various monitors, reading resident care instructions.
The ability to identify and distinguish colors
Examples: Identifying color changes in a resident (pale, flushed etc.)
The ability to detect scents and/or odors in the environment or surroundings
Examples: Smoke, burning, urine, feces.
Question 7: Communication:
Speaking: Providing and receiving routine information orally and in writing in English to perform job functions and to communicate with supervisors, coworkers and customers indicated by the needs of the audience.
Examples: Understanding the speech of another person, communicating face to face with individuals, via call systems, and telephone. Explaining cares being provided and encouraging residents. Providing information to co-workers & supervisors. Speaking to family members & other visitors.
Hearing: The ability to perceive sound
Examples: Hearing faint body sounds (e.g. heart, blood pressure), normal speaking levels (person to person, phone), and a range of tones (call systems, alarms).
Question 8: Learning Retention / Memory Concentration / Self Direction and Problem Solving
The following questions relate only to missed work time or restrictions in the past year.
As it relates to the core tasks (essential functions) of your job, have you had any injuries/surgeries/hospitalizations/treatments in the past year that resulted in missed work time or restrictions of any kind for any of the following?
Your job will include exposure to a variety of environmental conditions as outlined below.
Do you have any allergies or sensitivities outlined below that might interfere with your ability to perform the core tasks (essential functions) of the job?
Presbyterian Homes and Services will not disclose any of your personal information provided on this form, except as indicated below. The information you submit is secured and password protected as provided by state and federal law.
Personal information or information provided on this form will be kept confidential and private, will only be shared with Employee Health staff and will not be released unless there is legal or operational reasons for its release. All information is accessed on a strict need-to-know basis.