Research Institute for Tropical Medicine

Health Screening Program

Name: ____________________________ Date of Birth: ______________________ Position: __________________________ Please check the box that corresponds to your current health status Tuberculosis Screen Form YES Do you have any history of TB exposure? Do you have any history to positive TB test? Do you have any history to TB treatment? Have you ever had Chest X-ray for TB detection? Do you have allergy in TB test solution? If your answer is mostly yes answer the table below with the physician in the nursing service (Any positive symptoms warrant a mask and CXR) YES NO Persistent Fever? Persistent Coughing? (more than 6 weeks) Night Sweats? Coughing up blood? Unexplained Weight loss? NO

Hepatitis B Screen Form YES Have you missed the required series of Hepatitis B Immunization? Can attached documentation slip of Hepatitis B Immunization I dont have the record but know the dates of my Hepatitis B Immunization ____________, ____________, _____________ NO

I dont have the knowledge if I completed my Hepatitis B immunization and request the institution to provide me the Hepatitis B Immunization If the vaccine is given 10 years before; a Hepatitis B titer is needed contact clinic physician is needed. Measles, Mumps, Rubella I already have developed the following diseases: Measles, Mumps, and Rubella: (Can attached documentation from physician of confirmed case of Measles, Mumps, and Rubella) Measles Mumps Rubella YES Have you missed the MMR vaccination? Can attached documentation slip of MMR vaccination NO

I dont have knowledge of any vaccination of MMR, I request to provide me the MMR vaccination

Varicella (Chicken Pox) I already had a confirmed case of Varicella? (Can attached documentation slip from physician of confirmed case of Varicella)

YES Have you failed to receive Varicella immunization 2 shot series? Can attached documentation slip of Varicella Immunization I dont have the records but remembered the dates of my 2 shot varicella immunization __________, ____________

NO

I dont have knowledge of my Varicella immunity, I request the institution to provide me the Varicella vaccination

Pertussis (Whooping Cough) YES Have you missed to receive DPwT Immunization? Can attached documentation slip of DPwT immunization NO

I dont have knowledge of my Pertussis immunity, I request the institution to provide me the pertussis immunization Diphtheria YES Have you missed to receive DPaT Immunization? Can attached documentation slip of DPaT immunization NO

I dont have knowledge of my Diphtheria immunity, I request the institution to provide me the diphtheria immunization

Tetanus YES Have you missed to receive DPaT Immunization or DT immunization Can attached documentation slip of DPaT or DT immunization NO

I dont have knowledge of my Tetanus immunity, I request the institution to provide me the tetanus immunization Influenza Immunization YES Have you failed to receive annual Influenza immunization? If no until when is the validity of the taken immunization? I dont have Influenza immunization, I request the institution to provide me the Influenza immunization Rabies Vaccination I already have receive pre-exposure and post-exposure anti-rabies vaccination (Can attached documentation form of confirmed administration of anti-rabies vaccination) YES Have you failed to receive anti-rabies vaccination? I dont have tetanus vaccination, I request the institution to provide me the tetanus vaccination. (The following vaccination can be completed with then two months of exposure or immediately upon admission of this disease) Pneumococcal Disease YES Have you failed to receive pneumococcal polysaccharide vaccination I dont have a pneumococcal polysaccharide vaccination; I request the institution to provide me the vaccination. NO NO

NO

Meningococcal Disease YES Have you failed to receive meningococcal vaccination? I dont have a meningococcal vaccination; I request the institution to provide me the vaccination. Typhoid Vaccination YES Have you failed to receive a typhoid vaccination? I dont have a typhoid vaccination; I request the institution to provide me the vaccination. Hepatitis A YES Have you failed to receive a Hepatitis A vaccination? I dont have hepatitis A; I request the institution to provide me the vaccination. NO NO NO

Signature:_____________________________ Clinician Signature:____________________

CATEGORIZATION

If categorize at B, you are permitted to have an exposure to all areas in R.I.T.M If categorize at A, you are limited to only areas you are protected, until you completed enhancement program.

CATEGORIZATION SHEET

Categorize the new nurse under A if he/she has at least one YES under the Health Screening Form Categorize the new nurse under B if he/she has at least one NO under the Health Screening Form and if he/she has passed a documentation slip of having that king of disease (MMR, Varicella, Rabies) Categorization B limitation Dont expose the new nurse to areas wherein he/she have no protection yet Dog Bite Facility South Station (For Varicella and Influenza)