Student Health Assessment

Please complete the confidential form below prior to your first clinical date at St. Anthony.

Educational Institute Name (Or Other) *

Latex Allergy

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.

You may upload a copy of your immunization or health records here if able.

At this time, COVID-19 vaccinations are optional for students. If you have received the vaccine, please provide the following information:

Have you received a COVID-19 vaccination? *

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

Moderna First Dose Date:

Moderna Second Dose Date:

Moderna Boost Dose Date:

Pfizer First Dose Date:

Pfizer Second Dose Date:

Pfizer Boost Dose Date:

Johnson & Johnson Date:

Johnson & Johnson Boost Dose Date:

Please enter the date of your last flu vaccine if your Student Experience falls between October 1st through March 31st.

Date of Last Influenza Vaccine *

Measles/Mumps/Rubella (MMR) Immunization Date

Measles/Mumps/Rubella (MMR) Booster Date

Measles/Mumps/Rubella (MMR) Date of Positive Titer

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.

Date of 1st Hepatitis B Injection

Date of 2nd Hepatitis B Injection

Date of 3rd Hepatitis B Injection

Date of Hepatitis B Titer

Two Varicella vaccinations OR a positive titer will be accepted.

Chicken Pox / Varicella Vaccination Date

2nd Chicken Pox/Varicella Vaccination Date

Chicken Pox / Varicella Date of Positive Titer

Students consistently scheduled for 5 or more hours per week are required to have 2-step TB skin test. At least one step (skin test) must be completed within the 12 months prior to working at St. Anthony.
If needed, students may obtain a TB skin test from the St. Anthony Employee Health Nurse for a fee of $25.

TB Skin Test #1 Date *

TB Test #1 Lot Number if known

TB Test Results #1 in millimeters

TB Skin Test #2 Date

TB Test #2 Lot Number if known

TB Test Results #2 in millimeters

IGRA (Quantiferon Gold or T-spot) Results

Positive
Negative

IGRA (Quantiferon Gold or T-spot Date

List each hospital(s) where you have worked within the last 12 months. If none, state NONE.

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

1. Do you have tuberculosis?

2. Weight loss- unexplained beyond normal flucutations

3. Anorexia or loss of appetite for more than 2 months

4. Fatigue- interferes with daily living

5. Cough- persistent elevations over past few months

6. Fever- persistent elevations over past few months

7. Hemoptypsis- blood streaked sputum

8. Exposure to TB- within last 2 years

9. Abnormal Chest X-ray

10. A positive Tuberculin Skin Test

If you answered YES to any of these questions, please explain.

I have received training on Blood Borne Pathogen Prevention

Yes
No
I Don't Know

I have received training on Mandatory Child and Adult Abuse Reporting

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.

By typing in your full name, you attest to the validation of your application.

Prior to your first clinical date at St. Anthony, please complete the confidential form below.