[Skip to Content]
Upstate Medical University Logo
MENU

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 specifically for students should be accessed through the Employee/Student Health portal, https://eshportal.upstate.edu/. If you have difficulty accessing any of the forms below, please contact:

Bridget McCarthy, FNP
Senior Clinical Operations Manager
[email protected]
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.

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 interpreters, and temporary non-clinical personnel.

Visiting Student Clinical Groups must complete the Health Clearance Verification Form, have a school representative enter student information into NEMS for clearance review, and email form to ESH representative on form.

Annual Health Assessments

The NYS Department of Health Code (405.3) requires reassessment of the health status of all personnel as frequently as necessary, but no less than annually, to ensure that personnel are free from health impairments which pose potential risk to patients or personnel or which may interfere with the performance of duties. This requires completion of the Annual Health Assessment Questionnaire, including screening for risk of tuberculosis exposure, should be completed online through the ESH portal.

Please got to the Employee Student Health portal at https://eshportal.upstate.edu/, to update the Annual Health Assessment Questionnaire.

 

Respiratory Protection Clearance

Healthcare providers and/or staff who require an N95 respirator mask for respiratory protection when performing their work duties with patients or specimens, MUST schedule an appointment for their yearly mask fit testing AFTER completing the annually required education course, "Respiratory Protection Against Infectious Disease," on Brightspace (https://mylearning.suny.edu/.)

 Mask Fit appointments MUST be scheduled through the ESH Portal at https://eshportal.upstate.edu/.

You must be clean shaven in order to complete mask fit testing.

If you wear a PAPR, you DO NOT need an appointment for testing, unless you have not received PAPR training or wish to have mask fit testing. 

Annual PAPR education (New PAPR Education) is available on Brightspace at https://mylearning.suny.edu/.

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.

Top