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Act Now DME Medical Release of Information
Act Now DME Medical Release of Information
Step 1 of 2
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Medical Release
Please Download and Print Medical Release Form Here
Please also upload the following files: • Immunizations • Current Physical
Please note:
If you do not have any of these files immediately available, please upload everything else now, then send the remaining documents to
hr@actnowdme.com..
This WILL delay the processing of your application.
Employee Full Name
*
First
Middle
Last
Upload Medical Release Form, or Recent Physical Here
Drop files here or
Accepted file types: jpg, gif, png, pdf, doc, docx.
HEPATITIS B VACCINATION
I have already received the hepatitis B Vaccine.
I decline the hepatitis B Vaccine.
If interested with the hepatitis B vaccine, I may contact the local Health Department.
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine; I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series.
Initial Here (Optional)
Tetanus Vaccination
I understand that I have been requested to supply proof of Tetanus Vaccination or agree to the vaccination prior to placement with Act Now DME, LLC. However, I decline the Tetanus Vaccination. Further, I understand that my refusal may limit my placement options in that I understand I cannot be placed at an Act Now DME client (hereinafter “Facility”) that requires the Tetanus Vaccination.
Initial Here (Optional)
Therefore, in consideration of my employment with Act Now DME and placement at a Facility, I agree to hold harmless both Facility and Act Now DME, their owners, directors, employees, staff, and agents, from any and all liability arising out of my refusal of the Tetanus Vaccination.
Signature
*
Print Name
*
Date Signed
*
MM
DD
YYYY
Tuberculosis Screening Questionnaire
Employee
*
Date
*
MM
DD
YYYY
Last TB skin test date
*
MM
DD
YYYY
Results:
*
Negative
Positive
Last chest X-Ray date
MM
DD
YYYY
Results:
*
Negative
Positive
N/A
Comments:
Please indicate if you have had any of the following symptoms for four weeks or longer since your last chest x-ray:
• Chronic cough
*
Yes
No
• Production of sputum
*
Yes
No
• Blood-streaked sputum
*
Yes
No
• Unexplained appetite loss
*
Yes
No
• Unexplained weight loss
*
Yes
No
• Chest pains
*
Yes
No
• Increased fatigue / tiredness
*
Yes
No
• Shortness of breath
*
Yes
No
Comments:
The above health statement is true and accurate to the best of my knowledge and there is no evidence of pulmonary tuberculosis or contagion. I will visit my physician or local health department if my health status should change.
Applicant Signature
*
Print Name
*
Date Signed
*
MM
DD
YYYY
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