Aircraft Mechanic Health System

Caregiver Health Immunization/Titer/TB Requirements

St Charles Health System screens all new caregivers for Tuberculosis, Measles, Mumps, Rubella and Varicella immunity status, as recommended by the Center for Disease Control and Prevention. Caregivers with positions that are fully remote and located outside of the Central Oregon area are exempt from this screening unless otherwise noted. Hepatitis B verification is performed for positions that have an increased risk for bloodborne pathogen exposure. Vaccine records and the caregiver health forms attached need to be sent to *******@*******************.*** for review. You will be contacted to schedule an appointment with Caregiver Health to review your immunization requirements, prior to your start date. If you are unable to provide any of the documentation requirements, services will be provided to you as a vaccine administration and/or titer blood draw. Contract workers such as travel RNs do not need to submit records to caregiver health as records are managed by their contract company. Covid-19 Vaccine

Provide documentation indicating fully vaccinated status, caregiver can not start unless fully vaccinated

• 2 weeks must pass after second dose of 2-dose series (Pfizer or Moderna)

• 2 weeks must pass after single dose vaccine (Johnson & Johnson) Tuberculosis Screening

If history of a positive TB screening test, provide the following:

• Documentation of positive QuantiFERON Gold or T Spot blood test, skin PPD is not accepted

• Negative chest x-ray report indicating no active tuberculosis OR

• Medical documentation of INH treatment including dates If history of a negative TB screening, provide the following:

• Documentation of a negative QuantiFERON Gold or T Spot blood test completed within the last 12 months

• Skin PPD is no longer accepted

Measles, Mumps and Rubella Immunity

Please provide one of the following:

• Medical documentation of 2 MMR vaccinations at least 28 days apart OR

• Laboratory blood titers indicating immunity to Measles, Mumps and Rubella Varicella Immunity

Please provide one of the following:

• Medical documentation of 2 Varicella vaccinations at least 28 days apart OR

• Laboratory blood titers indicating immunity to Varicella Hepatitis B Immunity

If your position places you at increased risk for bloodborne pathogen exposure, provide the following

• Documentation of 3 Hepatitis B or 2 Heplisav-B vaccines AND

• Laboratory blood titer indicating immunity to Hepatitis B Tetanus, Diphtheria, Pertussis Vaccine (Tdap)

Provide documentation of 1 vaccine given after the age of 19 Flu Vaccination

Seasonal October 1 – March 31

• Documentation of seasonal flu vaccine. Caregivers who decline flu immunization must wear a mask during active flu season with guidance from infection prevention

Caregiver Health History Form

Name: Date of Birth: Phone Number: Email Address: Campus: Department: Job Title: Tuberculosis Screening YES NO

Have you ever been screened for Tuberculosis? Date of most recent test: Result: Have you ever had a positive TB screen? Date : Last chest xray: Have you ever taken medication for TB? Medication: Dates: Have you had temporary or permanent residence greater than 1 year in a country with high TB rate? Any country other than US, Canada, Australia, Northern or Western Europe Did you receive the BCG vaccine?

Do you have any of the follow symptoms of TB which cannot be attributed to a different disease: Coughing Fever/chills Unexplained weight loss Chest pains Coughing up blood Night sweats Increased fatigue Loss of appetite Do you have any conditions or take medication that will increase your risk for TB disease? Organ transplant HIV/AIDS Rheumatoid arthritis Chronic malabsorption syndromes Recent TB infection Diabetes End stage renal disease Immunosuppressed Have you had close contact with someone infected with TB or worked/lived in an area with high incidence of TB? Correctional institute, homeless shelter, IV drug users, nursing homes Please explain any YES statements:

Are you allergic to latex? YES NO Any other allergies: Do you have any skin conditions of the hand(s) that interfere with glove use or hand hygiene? Are you enrolled in a Workers’ Compensation Preferred Worker Program? IMMUNIZATION HISTORY

Check the box if you have documentation of the following and email records to *******@******************.*** Caregiver Signature: Date: Covid 19

Hepatitis B immunization and Titer

Measles Mumps Rubella immunization or titer

Varicella immunization or titer

Tdap immunization after age 19

TB CXR, documentation of treatment if past positive Influenza (October – March)

OSHA Respirator Medical Evaluation

Instructions

A review of this medical questionnaire must be performed in order to provide medical clearance or restrictions of your use of a respirator as part of yo respirator standard, 29 CFR 1910.134.

Please note: This form will be reviewed by St. Charles Caregiver Health. If you have any questions contact Caregiver Health at 541-***-****.

Fill out the OSHA Respirator Medical Evaluation Questionnaire to the best of your knowledge. If you answer yes to a question, please give additional details in the space provided next to the question and/or on the last page of the questionnaire.

Send completed form to Caregiver Health by email to:

@stcharleshealthcare.org

OSHA Respirator Medical Evaluation Questionnaire (Appendix C to Sec. 1910.134) Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print). Can you read? Yes No 1. Today's date:

2. Your name: 3. Your age: Date of birth: 5. Your height: ft. in. 6. Your weight: lbs. 7. Your job title: 8. A phone number where you can be reached by the health care professional who reviews this questionnaire: -

9. The best time to phone you at this number: 10. Has your employer told you how to contact the health care professional who will review this questionnaire? (check one):

11. Check the type of respirator you will use (you can check more than one category): X Powered-air purifying (CAPR)

Pg1

12. Have you worn a respirator? (check one):

If yes, what type(s)?

1. Do you currently smoke/vape tobacco or other substances or have you smoked/vaped in the last month? Yes No

2. Have you ever had any of the following conditions? Yes No

If yes, when and what happened?

When was your last seizure? Describe current treatment If yes, when and what happened? Does this prevent you from wearing a respirator or doing any part of your job? 3. Have you ever had any of the following pulmonary or lung problems? Yes No

If yes, when was your last asthma attack? What are your triggers for asthma attacks? Describe current treatment: Pg 2

YES NO

If yes, when? Describe treatment: YES NO

m that you've been told about

If yes, please describe: 4. Do you currently have any of the following symptoms of pulmonary or lung illness? YES NO

her people at an ordinary pace on level ground

think may be related to lung problems

If yes to any of the above, please describe:

5. Have you ever had any of the following cardiovascular or heart problems? Yes No

or feet (not caused by walking)

If you answered yes to any in section 5 explain and describe treatment: Do you have any current restrictions or limitations on your activities? Explain: Pg 3

Yes No

If yes, please describe: 6. Have you ever had any of the following cardiovascular or heart symptoms? Yes No

ticed your heart skipping or missing a beat

y be related to heart or circulation problems

If you answered yes to any in section 6 explain and describe treatment: 7. Do you currently take medication for any of the following problems? Yes No

If yes, list medications: 8. If you've used a respirator, have you ever had any of the following problems? If you've never used a Respirator, check the following sp

Yes No

If yes to any in section 8, please explain:

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire?

Pg 4

This section for Caregiver Health to complete

Name: DOB CG# red air-purifying respirator (CAPR)

ing respirator/N-95 respirator with restrictions-

Health Professional

Reviewer: Date: Pg 5

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AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Patient Name: Date of Birth: / / Address: City: State: Zip: Phone: Purpose for requesting information: Legal Insurance Personal Continuation of Care Other See Below Please complete the following section, using a separate form for each sender or recipient of the medical records. This form can be used for records of St. Charles Health System or records of other health care providers. Check one: From To Check one: From To

St. Charles Health Systems (all locations) or;

St. Charles Bend hospital

St. Charles Redmond hospital

St. Charles Madras hospital

St. Charles Prineville hospital

St. Charles Sage View

St. Charles Medical Group: write in clinic name(s).

Date Range of Services: to I authorize the following information to be released from the medical record(s): Note: Standard copy fees will apply subject to federal and state regulations.

Any & All Records (complete legal Health Record) or select from below:

Visit Summary (Includes: Provider Notes, History & Physical, Operative Report, Discharge Summary, Diagnostics - ie: Radiology, Lab, Cardiac tests)

Emergency Room Record

Lab Report(s)

Radiology Report(s)

Cardiac Tests

Itemized Billing Records

Other: I give St. Charles Health System permission to share my State, CDC, and / or OSHA recommended vaccination, immunization record, and diagnostic screenings (including but not limited to titers & TB, etc) with SCHS Operations and Human Resources in the capacity as my employer. Instructions:

1. Enter the name, date of birth, address, and phone number of the patient whose records you would like to send or receive. 2. Select the purpose of your request: legal, insurance, personal, continuation of care, or other (please specify). 3. Check with the ‘From’ or ‘To’ box, then identify and provide the contact information for the sender or recipient of the medical records, as applicable.

4. Check with the ‘From’ or ‘To’ box, then identify and provide the contact information for the sender or recipient of the medical records, as applicable.

5. Enter the date range of services for which you are requesting records. 6. This is the basic information that health care providers commonly request. Check the box / boxes stating what types of records you are requesting. If requesting other that what is stated, check “other” and write the information you would like.

Same name and address as listed above Other

Sender / Recipient Name:

Address: City: State: Zip: Phone: Fax: Note: Faxes are only sent to

other healthcare providers offices.

By Checking this box, I authorize release of

Radiology films, imaging / tracings for the

above dates by either of the following:

1) Central Oregon Radiology Associates

1460 NE Medical Ctr. Dr. Bend, OR 97701

Phone: 541-***-**** Fax: 541-***-****

or

2) St. Charles Health System

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NOTE: Complete Section 1 & sign and date Section 9

SCHS Operations and Human Resources in the capacity as my employer All as defined under Other - section 6 All as defined under Other - section 6 AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 9521 9/21

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I understand that the medical records may contain sensitive or specially-protected information. Please initial those types of sensitive information that you would like to have released. In some situations, state and federal law protect the following information. If this information applies to you, please indicate whether you would like this information to be released.

Alcohol, Drug or Substance Abuse Records Initial Required HIV Testing Records Initial Required Mental Health Records Initial Required Genetic Records Initial Required By signing this authorization form, I understand that:

● Requests for copies of medical records are subject to reproduction fees in accordance with federal and state regulations.

● I have the right to revoke (take back or change my mind about) this authorization at any time. To do this, a request must be made in writing and provided or mailed to the St. Charles Health System Manager of Health Information Management

● If I ask to revoke an authorization that was signed by me on a previous date, the request to revoke will not apply to records that were already copied and released as a result of the original and authorized request.

● No determination about treatment, payment, enrollment, or eligibility for benefits will be based on whether or not I sign this authorization form.

● I understand that federal confidentiality rules will not protect the medical information that I have authorized to be released, if it is released again by the organization or person that receives it.

● This authorization will expire one year from the date it is signed. Records Format (paper is the default if not marked):

Paper CD n/a

Delivery Options (Please note: Standard copy fees may apply subject to federal and state regulations):

U.S. Mail Pick up n/a

Patient or Authorized Representative Signature Date Print Name Caregiver ID #

(For Office Use Only)

Name of Caregiver Accepting Authorization Department

Photo ID checked

Note: This form is a permanent part of the medical record St. Charles Health Information Management 2500 NE Neff Road, Bend, OR 97701 Phone: 541-***-**** ext. 7784 Instructions cont:

7. In some cases, a health care provider may be prohibited from releasing those types of records that are not initialed. 8. Check the box indicating the format in which you would like to have the records sent or received. Note: Faxes are only sent to other healthcare provider’s offices.

9. The person authorizing the release must sign, date, print his or her name, and indicate his or her relationship to the patient. No drug and alcohol treatment records of a minor who is 14 years old or older, nor medical records of any type of a minor who is 15 years old or older, may be released without the minor’s written authorization if the minor is self-consented to the treatment associated with the records. St. Charles reserves the right to reject this authorization form if the legal authority of the representative cannot be validated. 10. St. Charles staff accepting the release must sign and document department. 7

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