Visiting Nurse Association Health Group

APPROVED TREATMENT FACILITIES FOR:

PRE-EMPLOYMENT PHYSICAL & WORKER’S COMPENSATION
INJURIES
*MUST choose from (1) of the following VNAHG Approved Pre-
Employment sites listed to have your physical exam completed.
All exams will be done without cost to you and information will be forwarded directly to the HR Dept.
If you have any questions, please call HR (732)-224-6918 or VNAHG Employee Health (732) 337-8486.

CENTRAL/SOUTHERN JERSEY LOCATIONS

Eatontown Medical
158 Wyckoff Road
Eatontown, NJ 07724
Phone: 732-544-9500

Community Medical Center

67 Route 37 West
Building #2 – 2nd Floor
Toms River, NJ 08755
Phone: 732-557-8064

Monmouth Medical Center

300 Second Avenue
Long Branch, NJ 07740
Phone: 732-923-6745
Concentra Urgent Care Concentra Urgent Care
210 Benigno Blvd. 800 Haddonfield Road
Bellmawr, NJ 08031 Cherry Hill, NJ 08034
Phone: 856-931-0691 Phone: 856-663-7690

VNAHG Community VNAHG Community

Health Center Health Center
1301 Main Street 188 East Bergen Street
Asbury Park, NJ 07712 Red Bank, NJ 07701
Phone: 732-774-6333 Phone: 732-219-6620
 Visiting Nurse Association Health Group
APPROVED TREATMENT FACILITIES FOR:
PRE-EMPLOYMENT PHYSICAL & WORKER’S COMPENSATION
INJURIES

*MUST choose from (1) of the following VNAHG Approved Pre-

Employment sites listed to have your physical exam completed.
All exams will be done without cost to you and information will be forwarded directly to the
HR Department.If you have any questions, please call HR (732)-224-6918 or VNAHG
Employee Health (732) 337-8486.

NORTH JERSEY LOCATIONS

Saint Barnabas Medical Center
101 Old Short Hills Road
Atkins-Kent Building
Suite 415
West Orange, NJ 07052
Phone: 973-322-6450
Clara Maass Medical Center
Continuing Care Building
1st Floor
1 Clara Maass Drive
Belleville, NJ 07109
Phone: 973-450-2175
JFK Medical Center
Occupational Medicine & Employee Health Services
742 Route 1 North
Iselin, NJ 08830
Phone: 732-362-3871
Concentra Urgent Care
150 North Street
Teterboro, NJ 07608
Phone: 201-393-9199
Concentra Urgent Care
190 Baldwin Road
Suite B
Parsippany, NJ 07054
Phone: 973-882-0444
 Employee Medical Requirements :(PLEASE READ BEFORE PHYSICAL)

As a requirement for employment with the VNA Health Group, you must have Physical Examination as well as
below items completed. You may PROVIDE COPIES OF RECORDS OR MD NOTES of below items as designated &
bring these copies to your physical.

You MUST HAVE these copies AT THE TIME of Physical to be reviewed for acceptance or ALL BELOW ITEMS
will be completed NEW AT THE TIME of Physical.

Employee Consents *ALL employees MUST complete & sign ALL VNAHG forms-
• Physical Demands
• Patient History
• VNAHG Physical Exam Form
• Hep B Consent
• Hep B Injection Consent (if received).
Drug Screen *ALL employees MUST complete new Drug Screen.

Physical Demands *ALL employees MUST sign form. Lift Testing REQUIRED for job duties that
involve lifting, transferring of patients and climbing stairs, etc.

Rubeola, Rubella & Mumps *May accept copy of all 3 Titers OR Immunization Record with 2 doses of
Copy of Record Accepted MMR after 12 months of age
-If NO immunization record, ALL 3 TITERS WILL BE DRAWN.

Varicella *May accept copy of all Titer OR Immunization Record with 2 doses of
Varicella Vaccinations after 12 months of age
Copy of Record Accepted -If NO immunization record, A NEW TITER WILL BE DRAWN.

TB Mantoux/PPD *MUST get Two (2) Mantoux Steps unless a copy of QuantiFERON or T- Spot
within last 12 months is provided.
Copy of Record Accepted
For 2 Step Process:
1. MUST get at least one (1) Mantoux through VNA or VNA
Approved Physical Location
2. May accept copy of one (1) Mantoux in the prior 12 Months
for 2 Step Process

TB Positive Reactors 1. MUST provide a copy of a POSITIVE: Mantoux, T-Spot QuantiFERON,

OR MD Note indicating CURRENT Positive Reactor
Copy of Record Accepted
• If NO Positive Record provided at physical, MUST get
new Mantoux/PPD Test.
2. MUST provide a copy of Chest X-ray within past 5 years
• If NO Chest X-ray record within 5 yrs, MUST get new
chest x- ray at physical.

Revised 10/20/2015 6/8/2016 11/14/2016 4/1/2018 1/1/2019 3/27/19, 10/20/20 CC

 Employee Medical Requirements :(Continued)

TDAP Vaccination *May accept copy of TDAP Vaccination received in 2012 or after
Copy of Record Accepted -If NO vaccination record, A NEW TDAP Vaccination will be given.

MMR Vaccination *MMR vaccinations offered to those not immune or equivocal to titers
MUST get at physical location if available.
(For those NOT IMMUNE to Measles,
Mumps, Rubella) -If Not Immune/Equivocal to RUBEOLA, MUMPS: 2 MMR Vaccinations are
required 4 weeks apart from each other.

-If Not Immune/Equivocal to RUBELLA: Only 1 MMR Vaccination is

required.

Varicella Vaccination *Varicella vaccinations offered to those not immune or equivocal to titers
MUST get at physical location if available.
(For those NOT IMMUNE to Varicella)
-If Not Immune/Equivocal to Varicella: 2 Varicella Vaccinations are
required 4 weeks apart from each other.

Flu Vaccination (Sept – Mar) *May accept copy of Flu Vaccination August 1st or After of Current Year
-If NO record, a Flu Vaccination will be given at Facility or VNAHG
Copy of Record Accepted
Orientation.

Employees may start series, continue series or get the Hep B Titer through
VNAHG Office or VNAHG Approved Pre-Employment facility.
HEP B Injections & Titer
Copy of Record Accepted **The only Hep B Vaccine Brand covered by VNAHG will be Heplisav-B –
Recombinant. VNAHG Hep B series consists of only Two (2) vaccine
injections + titer.

• 1st Hep B Vaccine can be done at time of physical.

• 2nd Hep B Vaccine is due 1 month after 1st Hep B Vaccine.
• Hep B Titer for immunity is 1 month after 2nd Hep B vaccine.

*If Series Partially or All Completed Prior to physical, MUST provide copy
of Hep B injection records (& Hep B Immunity Test if after 2005).

Revised 10/20/2015 6/8/2016 11/14/2016 4/1/2018 1/1/2019 3/27/19, 10/20/20

 VNAHG PRE-EMPLOYMENT PHYSICAL EXAM REPORT (Revised 10/15, 6/16, 11/16, 4/18,6/19,10/20/20)

Employee’s Name: Date of Examination:

1.  YES NO I certify that I have examined the above-named individual and found him/her to be free of any
addiction/ habituation to depressants, stimulants, narcotics, illegal drugs, or alcoholic substances.
2.  YES  NO Not Applicable Met requirements AS OUTLINED on PHYSICAL DEMANDS FORM
3.  YES  NO Reviewed OSHA Questionnaire with the above-named individual (This is Mandatory)
4. I certify that I have examined the above-named individual and found him/her to be:
Fully Employable – No limitations
Employable – Suggest Follow Up and/or completion of:
Not Currently Employable – Recommend Additional Testing /Treatment and/or Follow Up as soon as
possible for:
Health Care Provider’s Signature: Date: / /
Title: Phone #:
Address: Physical Location:
I consider my present health good and that the above medical history is correct and I am able to perform the duties of my
position. I give my permission to health care provider to release all health findings to my employer. I am aware that this information
is kept strictly confidential.
Employee Signature Date / /
PLEASE NOTE: CLINICAL STAFF DUTIES MAY INVOLVE - LIFTING, TRANSFERRING OF PATIENTS, WALKING, STANDING, CLIMBING STAIRS
DATE OF BIRTH / / HEIGHT WEIGHT PULSE BLOOD PRESSURE
RESPIRATIONS HEART SIZE HEART RHYTHM HEART MURMURS
CONDITION: SKIN EYES EARS NOSE THROAT NECK
THYROID LUNGS BREASTS SCROTUM SPINE BACK
EXTREMITIES LIMITATIONS OF MOTION
THE FOLLOWING TESTS ARE A REQUIREMENT PER STATE & FEDERAL REGULATIONS:
Documentation of Two (2)-Measles, Mumps, Rubella, Varicella Immunizations after age 12 months in lieu of titers. YES NO
Provide Titer Lab Report with Physical Clearance
Rubella Report Date / /  Immune  Equivocal  Not Immune MMR/VARICELLA NEEDED
Rubeola Report Date / /  Immune  Equivocal  Not Immune  YES  NO
Mumps Report Date / /  Immune  Equivocal  Not Immune
Varicella Report Date / /  Immune  Equivocal  Not Immune
MMR: Date Given _/ / Mfr. Lot# Date EXP _/ /
VARICELLA: Date Given / / Mfr. Lot# Date EXP _/ _/
Documentation of TDAP Vaccination In or After 2010 Provided  YES  NO Date GIVEN / /
OR TDAP Given: Date GIVEN / / Mfr Lot # Date EXP / /

DRUG SCREEN: COMPLETED RESULT:  Negative  Positive Provide drug screen lab results report
FLU VACCINATION: Date GIVEN / / Mfr Lot # Arm ( ) L ( ) R

MANTOUX: DATE ADMINISTERED / / Mfr Lot #

STEP 1 OF 2 STEP DATE READ / / RESULTS: MM  Negative (0-9mm)  Positive (+9mm)
PROCESS READ BY (NAME) (TITLE)
If positive, check if sent for x-ray  YES  NO -- Reason
STEP 2 MAY BE ADMINISTERED AT VNAHG – Results may be forwarded to Physical Location Site
MANTOUX: DATE ADMINISTERED / / Mfr Lot #
STEP 2 OF 2 STEP DATE READ / / RESULTS: MM  Negative (0-9mm)  Positive (+9mm)
PROCESS READ BY (NAME) (TITLE)
OR If positive, check if sent for x-ray  YES  NO – Reason
Positive Reactor: 1. Positive Documentation Proof  Yes  No
2. Chest X-ray within 5 years  Yes  No OR New Chest X-ray Performed  Yes  No
Employment Medical History Form PATIENT HISTORY RECORD
Name: Date of Birth:
Do you now have or have you ever had any of the following?
Check YES or NO. If YES, give YEAR of occurrence.
YES NO YEAR YES NO YEAR YES NO YEAR
Recurrent cough Rectal bleeding Back trouble
Coughing up blood Jaundice (yellow skin) Arthritis
Shortness of breath Leg pains Joint pains
Emphysema Ankle swelling Broken bones
Asthma Hernia Osteoporosis
Abnormal chest x-ray Urine problem Ear trouble, deafness
Tuberculosis history Cancer or tumor Eye/vision trouble
Dizzy spells Blood transfusion Nose trouble
Chest pain / Angina Anemia/blood disorder Throat trouble
Irregular heart beat Unplanned weight loss Kidney/bladder problem
Heart trouble/Heart Diabetes Eczema/hives/skin
attack problems
High blood pressure Seizures, Convulsions, Black stool
fits
Fainting spells Headaches Testicular/prostate trouble
Frequent indigestion Paralysis Breast lump/discharge
Vomiting of blood Numbness, tingling Stoke or TIA
Hepatitis A Emotional/mental illness Any Brain/Neurologic
illness
Hepatitis B Drug/alcohol problem Past MRI tests
Hepatitis C Latex/chemical sensitivity Other
Gallbladder trouble Wheezing Other

ALLERGIES:

List any significant health issues not mentioned above:

YES NO Amount Consumed Previous occupation(s):

Alcohol Previous work-related injury/illness? Yes No
Tobacco Type:
Former smoker? Have you ever been rejected for employment, military service or
Prescription drugs insurance for health reasons? Yes No
Non-prescription Why?
drugs
Have you ever received workers’ compensation benefits?
List injuries, illnesses, Surgeries, or Hospitalizations & Date(s): Yes No Describe:
Do you require accommodation/special assistance of any kind?
Yes No Describe:
Do you use any aids or assistive devices (prosthesis)?
Yes No Describe:

I certify that the answers to the above questions are true, correct and complete. I
understand that any false, incomplete or misleading information may be considered
sufficient grounds for immediate rejection or termination when discovered.

SIGNATURE OF APPLICANT DATE

 HEPATITIS B
IMMUNIZATION
QUESTIONNAIRE FORM
Rev. October 2020

As part of the Visiting Nurse Association Health Group response to OSHA Standard Occupational
Exposure to Blood Borne Pathogens, we offer the Hepatitis B Immunization to those who would like to
receive the immunization and have not received it previously or have not completed the series. As part of
that regulation, you must indicate your acceptance or declination of this opportunity.

 Please complete this form and return it to the Human Resources Department. If you have any
questions, contact Infection Control/Employee Health Manager -Anne Lefferts at 732-337-8486.

□ I do not want the immunization at this time.

I understand that due to my occupational exposure to blood or other potentially infectious
materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the
opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline
Hepatitis B vaccination at this time. I understand that by declining this 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 at no charge to me.
□ I have already received a complete series and do not have documentation and do not want the
immunization. Date completed:
□ I want the immunization and will schedule an appointment
□ I have already received a complete series and have documentation of 3 shots and titer.
DOCUMENTATION ATTTACHED.
□ I have received a partial series:
Number of Injections:
I will complete the series with VNACJ and will schedule an appointment □

I will not complete the series with VNACJ □

Name: ID#
(PLEASE PRINT)
Signature: Date:
Please Return to: Attn: Human Resources Department (or) Fax To: 732-747-2822
VNA Health Group
23 Main Street, Suite#D1
Holmdel, NJ 07733 For more Information about Hepatitis B
--- VNACJ Intranet ---
Human Resources – Forms – Hepatitis B

Note: Please up-date your information. IF YOU HAVE ALREADY COMPLETED THE SERIES OR ARE
IN THE PROCESS OF COMPLETING THE SERIES – we need the date of your inoculations. If
you have a record of the inoculations, we would appreciate a copy for your employee
file.
 Tdap Vaccine
(tetanus, diphtheria and acellular pertussis vaccine)

Name:
DOB: Department: _

PLEASE ANSWER ALL THE FOLLOWING QUESTIONS

1. □ Yes □ No Have you received Tdap vaccine or Boostrix in 2010 or after? If yes, please
Provide Documentation.

2. □ Yes □ No Do you currently have an acute illness or infection?

3. □ Yes □ No Do you currently have a progressive or unstable neurologic or uncontrolled
seizure disorder?
4. □ Yes □ No Are you on anticoagulant therapy or do you have a bleeding disorder?
5. □ Yes □ No Do you have a severe allergy to latex?

6. □ Yes □ No Have you had a systemic allergic reaction, any adverse reaction, seizure,
Guillain-Barre syndrome, coma or encephalopathy related to a previous tetanus and diphtheria
toxoid and/or pertussis vaccine? If yes, please provide an MD Note.

Question 8 for woman only

7. □ Yes □ No Are or might you be pregnant? If yes, you MUST consult your obstetrician
before getting Tdap and provide an MD note.

Tdap Consent
I understand that this is a one-time booster dose. As with all medical treatment, there is no
guarantee that I will become immune or that I will not experience an adverse side effect
from the vaccine. I request that this vaccine be given to me.

Employee Signature Date

Staff Use Only

Manufacturer Lot number Site: Arm L R

Administered by Date

PLEASE RETURN COMPLETED FORM TO VNAHG HUMAN RESOURCES

23 Main Street Suite#D1, Holmdel, NJ 07733 or Fax to: 732-747-2822
 Physical Demands/Frequency Form
Position/Discipline ACTIVITY LIFTING LIFT TEST REQUIRED
Sitting Standing Walking Fine Motor Hand Reaching/ Pushing Crouching/ 1-25 lbs. 26-40 lbs.
Movement Pulling Stooping
NURSE X
* ** ** ** ** * ** ** **
NP/APN/PA/MD * ** ** ** ** * ** ** * X
CMA/CNA * ** ** ** ** * ** ** ** X
Home Health Aide X
* ** ** * ** ** ** ** **
Speech Therapist ** * * ** * ** * * *

Occupational Therapist
** * ** ** ** ** * ** *
Physical Therapist X
* ** ** ** ** ** ** ** **
X
Social Workers * ** * ** ** * ** * * ( ONLY Early Intervention&
Special Child Health SWs)
WIC Staff * ** * ** ** ** ** ** ** X
Clinical Mgr/Field Mgr ** * * ** * * * * * X
Manager (Other) ** * * ** * * * * *
Support Staff (Clerical) ** * * ** ** * * * *
Support Staff
* ** ** ** ** ** ** ** ** X
(Maint/Facil/Escort/Mailroom)
Direct care providers may be exposed to various additional occupational hazards.

I understand the physical demands of my position. Employee Signature:

Employee meets physical demands for position (includes lift test, if required). Provider Signature:

FOR PHYSICAL EXAMINATION:

KEY: * = occasional Movement starts at chair height (never from the floor).
** = frequent Occasional = 1-2 times / Frequent = 3-5 times

Revised 10/2/19,6/21/17, 7/27/16, 6/3/02

 EMPLOYEE:
PLEASE REVIEW QUESTIONS- DR WILL REVIEW WITH YOU AT PHYSICAL
YOU DO NOT HAVE TO COMPLETE FORM

VISITING NURSE ASSOCIATION HEALTH GROUP

Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

To the employee:

Can you read? (Circle one) Yes No

Part A. Section 1. Please complete

1. Today’s date:
2. Your name:
3. Your age (to nearest year):
4. Sex (circle one): Male/Female
5. Your height: ft. in.
6. Your weight: lbs.
7. Your job title:
8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the
area code):
9. The best time to phone you at this number:
10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes
No
11. Check the type of respirator you will use (you can check more than one category): (For VNACJ choose: a.)
a. N, R, or P disposable respirator (filter-mask, non-cartridge type only)
b. Other type (for example, half – or full-face piece type, powered-air purifying, supplied-air, self-contained
breathing apparatus).
12. Have you worn a respirator (circle one): Yes No
If “yes”, what type(s):
Part A. Section 2. Please circle
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month:
Yes No
2. Have you ever had any of the following conditions?
a. Seizures (fits): Yes No
b. Diabetes (sugar disease): Yes No
c. Allergic reactions that interfere with your breathing: Yes No
d. Claustrophobia (fear of closed-in places): Yes No
e. Trouble smelling odors: Yes No

3. Have you ever had any of the following 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 (Over)

4. Do you currently have any of the following symptoms of pulmonary or lung disease?
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

5. 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

6. 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

7. 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

8. If you’ve used a respirator, have you ever had any of the following problems?
(If you’ve never used a respirator, check the following space and go to question 9) Never Used [ ]

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

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this
questionnaire: Yes No