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Download Health Attestation Form Health Attestation Form Clinician name: _
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Health Attestation Form Note: This is a sample template. Organizations are advised to consult with counsel particularly for any Human Resource (HR) recommendations. This model plan is intended as guidance to be adapted consistent with the internal needs of your organization. This plan is not to be viewed as required by ECRI Institute or the Health Resources and Services Administration. Proprietary and Confidential Copyright ECRI Institute, 2014 Page 1 of 4 Health Attestation Form Clinician name: ______________________________________________________________________________ Please explain any “yes” answers in the space provided on this form or by attaching a separate sheet. This form is confidential and will be kept in the clinician’s credentials file. Do you presently have any physical or mental condition that may affect your ability to perform clinical or professional Yes No duties? If yes, please explain: ___________________________________________________________________ Within the past five years, have you been treated in an inpatient or outpatient facility or have you missed work due to any Yes No physical or mental condition that may affect your ability to perform clinical or professional duties? If yes, please explain: ___________________________________________________________________ Do you presently suffer from an addiction to drugs, alcohol, or other chemical substances that may affect your ability to Yes No perform clinical or professional duties? If yes, please explain: ___________________________________________________________________ Within the past five years, have you been treated in an inpatient or outpatient facility or have you missed work due to an Yes No addiction to drugs, alcohol, or other chemical substances? If yes, please explain: ___________________________________________________________________ Are you currently taking any medications that may affect your ability to perform clinical or professional duties? Yes No If yes, please explain: ___________________________________________________________________ Do you have any communicable diseases? Yes No If yes, please explain: ___________________________________________________________________ Please provide the date of your most recent physical exam:_________ Performed by___________________________________________ Page 2 of 4 Proprietary and Confidential Copyright ECRI Institute, 2014 Please provide dates for the following vaccinations, diagnostic screening, and/or treatment MMR: __________ Varicella: __________ (or disease history: __________) Diptheria: ________ Hepatitis B: _______ _______ ________ or TwinRix series ________ _______ ________ Tetanus: __________ Influenza: __________ TB Screening History : PPD___________(Result__________) or IGRA____________(Result____________) Chest X-ray_________(Result)___________ Treatment completed for latent infection ___________________________or active disease____________________________ BCG _______ and IGRA___________(Result________________) If you declined any vaccinations or screening, please explain: ______________________________________________________________________________________________________________ __________________________________________________________________________________________ Please list any other physical or mental conditions that you think [name of health center] should be aware of: ____________________________________________________________________________________________________ ___________________________________________________________________________________________ I (please print full name) __________________________________ can attest that I am in good health and have no physical or mental conditions that may affect my ability to perform clinical or professional duties. I can also attest that I have no current addictions to drugs, alcohol, or any other recreational chemical substances. I understand that I may not hold [name of health center] responsible for any physical or mental conditions or addictions that I have or have not disclosed. Clinician signature: _______________________________________________________ Date: _____________________ Page 3 of 4 Proprietary and Confidential Copyright ECRI Institute, 2014 Reviewed by: Signature: ________________________________________________________________ Date: _____________________ Signature: ________________________________________________________________ Date: _____________________ Page 4 of 4 Proprietary and Confidential Copyright ECRI Institute, 2014
