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Employee Health Forms

The following forms must be used by employees, volunteers and affiliates to manage medical information. An 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:

Dorothea Scholes,
Office Manager
scholesd@upstate.edu
315 464-4260

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 >
    All employees must complete the first three pages pertaining to personal medical history.
  • Allergy History >
    All employees must complete this form to document pre-existing allergies, including latex.

Health Clearance for Non-Employees and Affiliates

Any non-employees (personnel not on an Upstate payroll) and affiliates are required to be screened for any communicable disease or health impairment that may pose a risk to Upstate patients and employees.  This health clearance process is accomplished by completing and submitting the Non-Employee Medical Clearance form (NEMC)> to the Employee/Student Health Office. 

Please note the following guidelines:

  • All non-employees who will be visiting either Upstate campus should complete the entire NEMC form, with the attestation statement signed by a healthcare provider (MD, NP, PA).
  • Copies of supporting lab work and/or immunization records are also required.
  • If the entire form is not complete, it will not be processed for clearance.  
  • Appropriate users of the NEMC form include but are not limited to: visiting students, visiting medical personnel, medical intrepreters, and temporary non-clinical personnel. 

Annual Health Assessments

In accordance with the New York State Health Code, Section 405.3, the health status of each employee, volunteer, student and affiliate is reassessed as frequently as necessary, but no less than annually, to ensure personnel are free from health impairments which pose potential risk to patients or personnel, or which may interfere with the performance of duties.

Annual Health Assessments (AHA's) provide us with the knowledge of any changes to your health status that have occurred in the preceding year. AHA’s consist of a health and wellness screening, tuberculin skin testing (if required), Mask-fit testing (if required), and updates to your Tetanus/Diphtheria immunization. These are done on a walk-in basis – no appointment is necessary. Please Note: AHA's cannot be done on Thursdays if a tuberculin skin test is required.

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.

Release of Medical Information

All transfer of personal medical information must be 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.

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