VA244-17-R-1154-005.docx

ATTACHMENT #4

VA PITTSBURGH HEALTHCARE SYSTEM

CONTRACT PHYSICIAN HEALTH REQUIREMENTS

Date: __________________________________________________ Contract Employee’s Name: ________________________________ DOB: ________________ Contract Physician: University of Pittsburgh Physicians Contract: ___________________ Contract Physician Contact Person: _____________________ Phone: ______________ COR: Sallie Gray Phone: 412-954-4034

OCCURRENCE/

IMMUNIZATION

CHICKENPOX

REQUIRED

Strong verbal history of recollection of having Chickenpox is acceptable.

If unsure or unknown, blood work to determine Varicella titer should be done. If not immune, 2 doses of Varicella vaccine are required. Document the following:

· Strong verbal history? Yes or No

· If no, unknown or unsure, date of Varicella titer and results:

· Vaccine dates if administered:

RUBELLA/

RUBEOLA

REQUIRED

IF BORN ON OR AFTER 1/1/57 PHYSICIAN DOCUMENTATION OF DISEASE, DOCUMENTATION OF RECEIVING 2 DOSES OF VACCINE, OR BLOOD TITERS SHOWING IMMUNITY IS REQUIRED. If not immune, 2 doses of MMR vaccine are required.

Document the following:

· Date of Rubella titer and results

· DATE of Rubeola titer and results

· Vaccine dates if administered

TB SCREENING

REQUIRED

TB Screening is to be done by Mantoux method (PPD) no longer than one year prior to starting an assignment at VAPHS and yearly thereafter. If HE/SHE HAS A HISTORY OF A POSTIVE PPD, THE INDIVIDUAL SHOULD HAVE DOCUMENTATION OF AN EVALUATION RULING OUT ACTIVE TB FROM THE ALLEGHENY COUNTY HEALTH DEPARTMENT OR THEIR PRIMARY CARE PHYSICIAN. If there is a past history of positive results, a questionnaire should be completed. This can be obtained by calling VAPHS Employee Health at 412-688-6000, X-815556.

Document

· The date of testing and results or

· Attach a copy of completed questionnaire.

IMMUNIZATION

TETANUS/DIPHTHERIA

ADVISED

Immunization within the last 10 years is recommended.

· This is advised and not a requirement. Document the date of last booster.

WORKERS’ COMPENSATION

Each Contract Physician should have a work injury report process in place to be reviewed with the worker before beginning an assignment at VAPHS. Document in this table the date the worker signed the Worker’s Compensation Acknowledgment. Each company will notify and will update when any information changes occur. Your company will notify the VAPHS Safety Manager, Joanne Faas, at 412-688-6000, X-815703 when a worker from your company is injured on the premises.

If a contract employee is injured while on duty, he should follow Contract Physician’s policy for injuries. If immediate treatment is needed, the VAPHS emergency room will provide humanitarian treatment. The individual will be referred to the Contract Physician’s worker compensation provider.

REQUIRED FOR PARTICULAR DEPARTMENTS

· A minimum of the initial Hepatitis B injection has been administered, if required.

If an assigned position puts the individual at risk for exposure to blood and body fluids, VAPHS will comply with OSHA’s Bloodborne Pathogens Standard regarding training and Hepatitis B Vaccine. If you have any questions on assignments putting individuals into this risk category, please contact Employee Health at 412-688-6000, X6035556.

Signature of Contract Physician Contact ____________________________________Date_________ Reviewed by VA Employee Health Nurse Approve/Disapprove (circle one) Comments:

Signature VA Employee Nurse: _________________________________________Date:____________