Annual Health Assessment

ANNUAL HEALTH ASSESSMENT

EMPLOYEE NAME (print)*

Date of last physical exam*

Date

Self assessment of general health status; pick one:*

ExcellentGoodFairPoor

Do you currently have any health limitations or risks which should be considered when making work assignements?*

YesNo

If you said yes to having health limitations or risks which should be considered when making work assignments, please describe:

Do you have any ongoing health problems which you have not described above that would interfere with your perfomrance of duties, or be a potential risk for patients/families or other employees?*

YesNo

If yes, please describe

The Annual Health Assessment is required by the New York State Department of Health, which requires assessment of the health status of all personnel, to assure that personnel are free from health impairments which pose potential risk to patients or personnel, or which may interfere with the performance of duties.

Accordingly, this assessment is done for the purpose of determining limitations employees self-report on their ability to perform their job, whether their job might present a possible risk to themself or whether they might present a possible risk to patients or co-workers.

If you have indicated a health limitation or potential health risk, it is advised that you seek proper assessment by a health care professional.

As a Hospicare staff member, volunteer, or contracted employee, I attest to answering these questions accurately and by checking this box and signing my name below, I am electronically signing this form.

Employee Signature*

Date*

Date