Occupational Health Services Registration and Consent
INSTRUCTIONS: PLEASE PRINT LEGIBLY AND COMPLETE ALL BLANKS. IF THE QUESTIONS IS NOT APPLICABLE USE (N/A.) PRINT YOUR NAME AS IT APPEARS ON YOUR PROFESSIONAL LICENSE OR SOC. SEC. CARD NAME:
SOCIAL SECURITY #
PHONE (home):
CELL
ADDRESS:
EMAIL: APT#
PAGER
CITY:
STATE:
ZIP CODE:
AGE: DATE OF BIRTH: FEMALES ONLY: MAIDEN NAME:
SEX: F M RACE: W B H Other OTHER LAST NAMES USED
Marital Status: S M D
Have you ever been a patient, employee, or student at Jackson memorial Hospital before? If yes, under what name(s) were you admitted?
Yes
No
Year(s)
Acknowledgement of Pre-Placement Drug Testing and Health Requirements
My signature below means that I understand that All JHS employees must participate in a physical exam, complete all immunizations and provide a urine specimen for drugs of abuse testing within 30 days of the first day at work. I understand that if I do not complete health screening as requested by Occupational Health Services, I am confirmed positive for illegal drugs or unauthorized use of a controlled substance, or I am considered to have refused a drug test, I will not be allowed to work for Jackson Health System and will be separated from employment, Graduate Medical Education Program or any other Jackson Health System program for which I am required to have pre-placement health screening. If I am required to provide a urine specimen for drugs of abuse, I understand that my urine will be tested for narcotics, depressants, hallucinogens, stimulants, marijuana, alcoholic beverages or other controlled substances. Testing is performed according to the Drug Free Workplace Act and the Miami- Dade County Scientific and Administrative Protocol. I will be considered to have a positive drug screen if my urine is positive for an illegal substance, positive for a controlled substance without a valid medical prescription, my breath analysis is positive for alcohol, or I refuse to provide a drug test or I take any action that may delay or adulterate testing. I also understand that licensed professionals who have a confirmed positive drug test will be reported to the Florida Agency for Health Care Administration Licensing Board and/or to the Impaired Nurse Program or Physician Referral Network if eligible to participate, and that all expenses for further medical evaluations as a result of a positive drug test or appeal will be the responsibility of the applicant. I have read Occupational Health Services Instructions for PrePlacement Health Screening and understand and agree to complete the health screening, immunizations, blood tests required, and deadlines for submitting required forms and for scheduling drug test appointments, and instructions for preparing for the drug test, respirator fit test and any other examinations required before or after arrival at Jackson Health System.
Authorization for Release of Information (Under 18 Requires Legal Guardian)
I agree to allow Jackson Health Systems Occupational Health Services to contact my Health Care Provider and obtain information from my medical records for the purposes of determining my fitness to work and to verify immunizations, lab tests, x-rays and other required communicable disease information required by Jackson Health System. I am willing for a faxed copy of this authorization to be used as an original.
Signature:
Page 1 of 1
Date: ________________
