36C24420Q0150-002.pdf

All Contract employees, to include echo technicians, providing services at the EVAMC are required to comply with the facilities immunization policy. As such, Contract employees must submit proof of health care requirements (as indicated below). No Contract employee will be authorized to commence work until all health care requirements are met and cleared by the VA Employee Health.

Date:

Company/Vendor:

Worker’s Name: SSN# (last four only): Date of Birth:

Immunization Requirement

Chickenpox Required

Strong verbal history? Yes no If no, unknown or unsure, date of Varicella titer and results:

Date_______ Immune Yes___ No___ If non immune dates of 2 doses of Vaccine required 1._______ 2._______

Rubella/Rubeola Required

IF BORN ON OR AFTER 1/1/57 provide ONE of the following:

Physician documentation of disease Dates of receiving 2 doses of MMR 1.______ 2.______ Date of rubella titer______ immune Yes____ No____ Date of rubeola titer ______ immune Yes____ No____ (if non immune 2 doses of MMR vaccine is required)

Hepatitis B vaccine if at risk for occupational exposure to BBP

Dates of vaccine 1.______ 2.______ 3._______ Offered but refused yes____ no_____

TB Screening Required

TB Screening is to be done by Mantoux method (PPD) no longer than one year prior to starting an assignment at Erie VAMC. If test result is positive, (10mm or >) the individual should be referred to the Erie County health Dept. or their Primary Care Physician for documentation of evaluation to rule out active TB. If there is a past history of positive results, a questionnaire should be completed. This can be obtained by calling Erie VAMC Associate Health at (814) 860-2232. Document in this table the date of testing and results or attach a copy of completed questionnaire. PPD date_______ Result ______mm

Approved____ Not approved____ by____________________________ date_________

Attachment B: Erie VAMC Health Requirements