Incoming Resident Information
Please complete the following forms:
Completed by HCP and enclose laboratory copies of titer results.
To All Residents:
All of these forms should be mailed or faxed to Employee/Student Health prior to arrival in Syracuse for the health office staff to review. If a former employee, volunteer or student, please contact Employee Student Health prior to completing the forms.
If you are in the Syracuse area
prior to orientation, you can contact Employee/Student Health at
(315) 464-4260 to arrange a TST and mask fitting. This will save time at orientation.
Employee Health Forms
The following are forms routinely used in the Employee/Student Health office to document medical information for staff. Explanation of the proper use of each form is provided. However, if there are questions about which form to use, contact the Health office for further explanation to avoid completing and submitting the incorrect form.
Forms specific for students should be accessed on the Student Health website.
If you have difficulty accessing any of the forms below, please contact:
Jane Bennett, MSN, NP, Nurse Administrator, bennetja@upstate.edu , 315 464-4260.
Transfer of Medical Information
All transfer of personal medical information must me initiated by the use of a release of information form in an effort to preserve confidentiality, to comply with HIPPA regulations and to maintain a record of the information transfer.
Medical History/Physical Exam
All new staff (employees and volunteers) must complete the medical history form and undergo a physical exam. The physical exam is performed at the Health Office with the following exceptions. Volunteers, incoming residents and professional staff may submit an exam from their private provider.
- Medical History
 text
All employees must complete the first three pages pertaining to family and personal medical history.
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Allergy History
text
All employees must complete this form to document pre-existing allergies, including latex.
Respiratory Protection Clearance
All incoming residents and employees providing direct patient care in respiratory isolation need to complete this form for review by health office staff. When medical clearance is completed, the employee will be mask fitted by Employee Student Health or Environmental Health & Safety.
Other Health Clearance Forms
All personnel, not on Upstate payroll, with potential for patient contact must be screened for health impairment that may be detrimental to patients for other personnel. This accomplished by the appropriate health status form prior to starting. The form required will depend on the extent of patient contact and/or time spent in the clinical area.
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Short-term Health Statement text
This form is used for a limited length of time (3 days or less in any month) in the medical facility and minimal patient contact. It requires a statement from the individual regarding current health status. Appropriate uses are for vendors, insurance company representatives or observers that fit the above criteria.
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Detailed Health Statement text
This form is used for individuals with patient contact and more extended time in the medical facility or with recurring entry, exceeding three days within any given month. It requires a detailed statement regarding health status, documentation of immunization status and tuberculin skin testing. Appropriate use is for interpreters or representatives of home care agencies.
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Certificate of Health text
This form is to be used as a minimum requirement for designated individuals not employed by the facility but have extended time spent in the facility and/or have extended patient contact. This form is most often used for temporary(agency) employees and visiting medical personnel.
- Certificate of Health Instructions text
You may access detailed Certificate of Health Instructions to guide you in proper completion of the Certificate of Health form.
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