Woods & Water Medical Center

Employee Information Report

Completed health information must be received with prior employment.
Name (first, MI, last) Date of Birth

Address City State ZIP

Phone No. E-mail Address

Social Security No. Dates at Clinic

Tuberculin skin test

 Two-step PPD results are required if you have never been tested or if it has been more than 12 months.
 PPD results are required if you have been tested within the last 12 months.
If a positive PPD, you need to provide PROOF of all of the following:
 Date of positive TB result including MM induration
 Copy of chest x-ray including the date of x-ray
 Annual TB questionnaire
Titer/Immunization/Disease Date(s) Result PPD Results
History
PPD date placed
Measles (Rubeola)
PPD date read
Rubella
PPD result mm
Chicken pox (varicella) Two-Step PPD Result
PPD date placed
Mumps*
PPD date read
Hepatitis B
PPD result mm
*Attach documented proof of health information verifying above information.

Signature of health care provider Health care provider’s address/phone

**Hepatitis B immunizations is highly recommended for any student/resident who may come in contact with patients, blood,
and/or certain body fluids.

Note:
 Immunization/history of disease documentation can be used instead of titers/tests.
 Individuals who test nonimmune to Rubella, Rubeola (measles), Varicella (chickenpox), and/or Mumps must be immunized
and may work with proof of re-immunization.
Have you worked for the Woods & Water Medical Center System? YES NO If yes, when
If you have any questions, call 1-715-555-2222, option 2 or FAX 715-555-5555.
Return to Woods & Water Medical Center, Medical Education—123 Main Street, Rice Lake, WI 54868.

For Office Use Only

I have reviewed the above information and find that it meets the medical complex standards for this program.

Approved by Center Date

Comments

WOODS & WATER MEDICAL CENTER FOLLOWS CDC IMMUNIZATION GUIDELINES OF HEALTH CARE WORKERS.