New, ACGME, US Medical Graduate, Licensed
2014 Housestaff Appointment Checklist and Cover Sheet
Office of Graduate Medical Education, UCSF
Please fill out this form completely and attach to the complete appointment packet for submission to the GME Office. Please place all paperwork in the order listed on this form. Do not include any paperwork in this packet that is not listed below.
Trainee Name / «TraineeName_» / Program Name / «ProgramName»PGY / «PGY» / Salary / «Salary»
Program Coordinator / «Coordinator» / Program Director / «ProgramDirector»
Coordinator Phone / «Coordinator_Phone» / Date Packet to GME
Document / Attached / GME Approved
E*Value Entry / Yes / No / Yes / No
Contract Letter (signed by Director, Chair and trainee) / Yes / No / Yes / No
Attestation (signed by trainee and Director) / Yes / No / Yes / No
CA Medical License / Yes / No / Yes / No
CV (ERAS application okay, but CV preferred) / Yes / No / Yes / No
Respirator Clearance / Yes / No / Yes / No
Abuse Reporting Form / Yes / No / Yes / No
Health Statement (signed by health care provider) / Yes / No / Yes / No
Two PPDs or Chest X-Ray / Yes / No / Yes / No
HIPAA Confidentiality Statement / Yes / No / Yes / No
Competencies (signed by trainee and Program Director) / Yes / No / Yes / No
Please explain any missing documentation.
GME Comments
UCSF Medical Center
Employee Health Services
2380 Sutter, 3rd Floor Box 1661
Phone: (415) 885-7580
Fax: (415) 771-4472
Respirator Medical Evaluation Questionnaire – N95 (Respiratory Isolation Mask) (1/3/07)
Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
To the employee: Can you read? (choose one): Yes No
Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.
Part A. Section 1. (Mandatory) the following information must be provided by every employee who has been selected to use any type of respirator (please print).
Name: / Date:Phone # (where you can be reached by the health care professional who reviews this questionnaire):
The best time to reach you at this number: / Alternate #:
Job Title: / Department: / Email:
Employer (check one): / UCSF Medical Center / UCSF Campus / LPPI / Traveler
Other
Age (to nearest year): / Sex: Male Female / Height: / Weight: / lbs.
Birthdate: mm/dd/yy
1. Has your employer told you how to contact the health care professional who will review this questionnaire?
(choose one) Yes No
2. Have you worn a respirator? (choose one) Yes No
If “yes”, what type(s)Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please indicate “yes” or “no”.
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes No
1. Have you ever had any of the following conditions?
a) Seizures (fits) Yes No
b) Diabetes (sugar disease) Yes No
c) Allergic reaction that interfere with your breathing Yes No
d) Claustrophobia (fear of closed-in places) Yes No
e) Trouble smelling odors Yes No
2. Have you ever had any of the flowing pulmonary or lung problems?
a) Asbestosis Yes No
b) Asthma Yes No
c) Chronic bronchitis Yes No
d) Emphysema Yes No
e) Pneumonia Yes No
f) Tuberculosis Yes No
g) Silicosis Yes No
h) Pneumothorax (collapsed lung) Yes No
i) Lung cancer Yes No
j) Broken ribs Yes No
k) Any chest injuries or surgeries Yes No
l) Any other lung problem that you’ve been told about Yes No
Please complete the back of this form…turn the page…thanks!
3. Do you currently have any of the following symptoms of pulmonary or lung illness
a) Shortness of breath Yes No
b) Shortness of breath when walking fast on level ground or walking up a slight hill or incline Yes No
c) Shortness of breath when walking with other people at an ordinary pace on level ground Yes No
d) Have to stop for breath when walking at your own pace on level ground Yes No
e) Shortness of breath when washing or dressing yourself Yes No
f) Shortness of breath that interferes with your job Yes No
g) Coughing that produces phlegm (thick sputum) Yes No
h) Coughing that wakes you early in the morning Yes No
i) Coughing that occurs mostly when you are lying down Yes No
j) Coughing up blood in the last month Yes No
k) Wheezing Yes No
l) Wheezing that interferes with your job Yes No
m) Chest pain when you breathe deeply Yes No
n) Any other symptoms that you think may be related to lung problems Yes No
4. Have you ever had any of the following cardiovascular or heart problems?
a) Heart attack Yes No
b) Stroke Yes No
c) Angina Yes No
d) Heart failure Yes No
e) Swelling in your legs or feet (not caused by walking) Yes No
f) Heart arrhythmia (heart beating irregularly) Yes No
g) High blood pressure Yes No
h) Any other heart problem that you’ve been told about Yes No
5. Have you ever had any of the following cardiovascular or heart symptoms?
a) Frequent pain or tightness in your chest Yes No
b) Pain or tightness in your chest during physical activity Yes No
c) Pain or tightness in your chest that interferes with your job Yes No
d) In the past two years, have you noticed your heart skipping or missing a beat Yes No
e) Heartburn or indigestion that is not related to eating Yes No
f) Any other symptoms that you think may be related to heart or circulation problems Yes No
6. Do you currently take medication for any of the following problems?
a) Breathing or lung problems Yes No
b) Heart trouble Yes No
c) Blood pressure Yes No
d) Seizures (fits) Yes No
If “yes, name the medications if you know them: ______
______
7. If you have used a respirator, have you ever had any of the following problems? (If you have never used a respirator, check the following space and go to question 9) ______
a) Eye irritation Yes No
b) Skin allergies or rashes Yes No
c) Anxiety Yes No
d) General weakness or fatigue Yes No
e) Any other problem that interferes with your use of a respirator Yes No
8. Would you like to talk to the health care professional who will review this questionnaire about answers to this questionnaire? Yes No
ASSESSMENT – TO BE COMPLETED BY A NURSE OR PHYSICIAN IN EMPLOYEE HEALTH SERVICES
Employee is cleared to perform job duties with use of a respiratorEmployee needs an appointment with Employee Health Services for further evaluation
Other recommendations:
Employee Health RN/NP/MD Signature______Date ______
G:\1 Current\Appointments\14-15 Appointments\Packets 2014-15 (mail merge)\NEW Mail Merge\A_complete_mail_NEW-2.doc
ADULT/CHILD ABUSE AND DOMESTIC VIOLENCE REPORTING REQUIREMENTS
California law requires that medical practitioners, non-medical practitioners, health practitioners and child care custodians working in specified public or private facilities be informed of their duty to report suspected child abuse, suspected dependent adult abuse, and suspected domestic violence. Please read the following carefully and sign where indicated:
Section 11166 of the Penal Code requires any child care custodian, medical practitioner, non-medical care practitioner or employee of a child protective agency who has knowledge of or observes a child his or her professional capacity or within the scope of his or her employment whom he or she suspects has been the victim of a child abuse to report the known or suspected instance of child to a child protective agency immediately or as soon as practically possible by telephone and to prepare and send a written report thereof within 36 hours of receiving information concerning the incident.
Any person who fails to report an instance of child abuse which he or she knows to exists or reasonably should know to exist, as required, is guilty of misdemeanor and is punishable by confinement in the county jail for a term not to exceed six months or by a fine of not more than one thousand dollars ($1,000) or by both.
The law also provides that a person who does not report as required, or who provides a child protective agency with access to a victim, shall not be civilly or criminally liable for doing so.
Section 15630 of the Welfare and Institutions Code requires any care custodian, health practitioner, or employee of a health facility who is in his or her professional capacity, or within the scope of his or her employment of a health facility who is in his or her professional capacity, or within the scope of his or her employment, has knowledge of or observes a dependent adult who he or she knows has been the victim of physical abuse, or who has injuries is under circumstances which are consistent with abuse, to report the known or suspected instance of physical abuse to an adult protective services, agency or a local law enforcement agency immediately, or as soon as practically possible, by telephone, and to prepare and send a written report thereof within 36 hours of receiving the information concerning the incident. Reporting is required where the dependent adult’s statements indicate, or in the case of a person with developmental disabilities, where his or her statements or other corroborating evidence indicates that abuse has occurred.
Sections 11160-11163 of the California Penal Code require that any health practitioner employed in a health facility, clinic or physician’s office who, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a patient whom he or she knows or reasonably suspects has suffered from any wound or injury inflicted as a result of domestic violence or spousal abuse shall immediately, or as soon as is reasonably possible, file a telephone report to the local law enforcement agency followed by a written report within two working days.
Failure to comply with these reporting requirements may lead to a fine up to $1,000 and/or six months in jail.
A health practitioner who makes a report in accordance with this article shall not incur civil or criminal liability as a result of any report required or authorized by this article.
I certify that I have read and understand this statement and will comply with my obligations under the dependent adult abuse, child abuse, and domestic violence reporting laws.
«TraineeName_»Name (Please Print) / Position
Signature / Date
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UNIVERSITY OF CALIFORNIA SAN FRANCISCO
SCHOOL OF MEDICINE, GRADUATE MEDICAL EDUCATION
2014–2015 Health StatementFor NEW Residents and Fellows
«FirstName» / «MiddleName» / «LastName» / Resident / Fellow
First Name / Middle Name / Last Name / Work Status (Please Circle One)
«SSN» / «ProgramName» / «DOB» / «Gender»
Social Security Number / Program / Date of Birth / Gender
«TraineeEmail» / «TraineePhone_Mobile»
Current Email / Current Phone Number
You must complete these forms in full, regardless of whether YOU PROVIDE additional documentation. Only complete forms will be accepted.
· The attached “Pre-Placement Health Statement” and “TB Skin Test Reporting Form” should be completed by your primary care provider (or the Student Health Service of your medical school) prior to the start date of your appointment. Failure to comply will delay processing of your UCSF Resident/Clinical Fellowship appointment.
· A physical examination must be performed under the direction of a physician as a condition of employment in a hospital. The individual to be employed should be free of symptoms that indicate the presence of an infectious disease.
· Immunity to rubella, measles, mumps, and varicella is required. The required screening tests and/or vaccinations are identified on the attached “Pre-placement Health Statement for New Residents and Fellows.”
· Although immunization for hepatitis B is not required, it is strongly recommended. If the hepatitis B vaccination has not been acquired or if a positive titer result has not been obtained, then the attached declination form must be completed.
· Immunization for Tetanus, Diptheria, and Acellular Pertussis (TDAP) is required. Vaccination must have been obtained in 2006 or later.
· Screening for Tuberculosis is also required. Both positive and negative PPD readings must be recorded in millimeters.
o For individuals with a history of negative TB skin tests, please do the following 1) provide the results from one TB skin test within the last two years, and 2) provide the results of a TB skin test completed after March 1, 2014 (for June/July 2014 start dates – all others must have second test done within 3 months of start date). In lieu of two PPD test results, you may provide one negative QuantiFERON test result within 12 months of start date.