St. Anthony Employee Health Assessment

• Yes
• No

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. 

St. Anthony requires staff to receive a flu vaccination before the start of employment.

• Yes
• No

To comply with the federal mandate, St. Anthony is requiring staff to have completed the COVID-19 vaccination series before the start of employment.

• Yes
• No

If YES, please provide the information about your particular COVID-19 vaccine. 

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. 

Two Varicella vaccinations OR a positive titer will be accepted.

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

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

To comply with the federal mandate, St. Anthony is requiring staff to have completed the COVID-19 vaccination series before the start of employment. 

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No
• I don't know

• Yes
• No
• I don't know

• Yes
• No
• I don't know

• Yes
• No
• I don't know

• Yes
• No
• I don't know

• Yes
• No
• I don't know

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