ASSOCIATE HEALTH ASSESSMENT

Saint Mary of Nazareth Hospital – Chicago

Prime Healthcare Senior Living – Fox Knoll Village

Prime Healthcare Senior Living – Heritage Village

Prime Healthcare Senior Living – Heritage Village, Lodge

Prime Healthcare Senior Living – Resurrection Place

Prime Healthcare Senior Living – Villa Franciscan Place

I would like to be vaccinated, please refer me to Employee Health

Associate attests to previous vaccination

ACCEPTANCE STATEMENT. If you accept to receive the hepatitis B vaccine, you are urged to report to Employee Health no later than 10 working days from your initial assignment. I, the undersigned, acknowledge that my employer, Prime Healthcare Services, has offered the hepatitis B vaccination series to me at no cost. I have been informed of the biological hazards that exist in my workplace, and I understand the risk of exposure to blood or other potentially infectious materials involved with my job. I wish to receive the Hepatitis B Virus Vaccine.  (Associates who have reasonably anticipated contact with blood or other potentially infectious materials during performance of their jobs are considered to have occupational exposure and to be at risk of being infected.)

DECLINATION STATEMENT. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccination at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

ASSOCIATE HEALTH ASSESSMENT

Hospital/Facility (select one from the drop down menu)

ASSESSMENT OF IMMUNITY AND VACCINATION RECORD

MMR (Measles, Mumps, Rubella) – 2 doses; Positive titer, regardless of date. I have had both doses of MMR

Associate Initials

Varicella – 2 doses; or documentation of diagnosis of chicken pox or shingles (herpes zoster). I have had both doses of Varicella

Associate Initials

Pertussis Tdap (Tetanus, Diphtheria and Pertussis) – 1 dose as adult. I have had one dose of Tdap as an adult

Associate Initials

I have answered NO to one or more of the above statements and wish to be referred to Employee Health for vaccination