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St. Anthony Employee Health Assessment

Welcome to the St. Anthony Hospital team!

This Employee Health Assessment is an essential aspect of your employment within our healthcare system. Please read thoroughly before beginning.
You will need to gather the following documentation and dates to complete the health form below. 
 

  • Digital copy of childhood immunization record (if possible)
  • MMR vaccine date or titer date
  • Hep B vaccine date or titer date
  • Chicken Pox vaccine dates or titer date
  • TB Test date
  • Digital copy of Mandatory Reporter Training certification 
  • Digital copy of American Heart Assoc. Life Support Training certification

All fields marked with * are required.

St. Anthony Regional Hospital Employee Health Assessment
Immunization & Vaccination History

Please upload a copy of all past immunizations, including all those received as an infant or child and / or you may continue to sections below. 

Influenza Vaccine

Seasonal flu vaccination is required for all employees during flu season. 

Measles, Mumps, Rubella (*MMR) A total of two MMR's or a blood test (titer) showing positive immunity is required.
Hepatitis B

Hepatitis B vaccinations are not a requirement, but recommended for anyone at risk for exposure to blood and/or blood products. A declination must be completed if applicable. 

Varicella (Chicken Pox)

Two Varicella vaccinations OR a positive titer will be accepted.

Tuberculosis (Please provide official TB skin test, Quantiferon Gold, or T-Spot TB Test results)
Tuberculosis Screening (REQUIRED) Answer each question

Have you had any of these signs/symptoms in the last year?  (All questions must be answered.)

Past Training Received

I certify that all of the statements provided here are true and correct to the best of my knowledge.