Communicable Disease Assessment Form

Communicable Disease Assessment
Instructions
1. READ the information provided on this page.
2. COMPLETE the form on page 2 in full.
3. SUBMIT the completed page 2 form to your local Workplace Health & Safety office, following the
instructions provided on page 3. THE COMPLETED FORM MUST BE SUBMITTED PRIOR TO YOUR
START DATE WITH ALBERTA HEALTH SERVICES.
Communicable Disease Assessment Information
The health, safety and wellbeing of our workers are fundamental to the provision of safe and quality health
services. As a new employee or physician of Alberta Health Services (AHS), it is your responsibility to be
involved in health, safety and wellness matters that impact the workplace. Your contact with patients puts you
and your patients at risk for contracting and transmitting communicable diseases.
AHS asks all new employees and physicians to complete a Communicable Disease Assessment (CDA) and
submit to Workplace Health and Safety prior to beginning work. The CDA will be used to ensure your ability to
work safely without risk of spreading or contracting communicable diseases. After reviewing your history, AHS
may recommend additional immunizations or follow up to ensure you, your patients and your coworkers are
protected from communicable disease.
Your personal and health information (including your Personal Health Number) on this form is collected under
the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act (“FOIP”) and sections
20(b), 21, and 27(1) and (2) of the Health Information Act(“HIA”), respectively. The information will be used by
or disclosed by AHS as authorized by the HIA and FOIP, primarily for the purposes of:
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performing the communicable disease assessment to minimize the risk of contracting or spreading
communicable diseases in the workplace;
providing a health service, including determining your eligibility to receive certain immunizations as an
employee of AHS;
determining your immunity and any associated risks to you or the patients you work with in the event of
a communicable disease exposure and/or outbreak;
planning, resource allocation, management of the health system and administration of human
resources; and
activities related to AHS’ mandate to protect and promote public health.
For the purposes described above, a Workplace Health and Safety Occupational Health Nurse(OHN)will
access the following information about you that may be held in AHS’ electronic systems:
1. previous immunization history and/or
2. lab results related to immunity for any of the recommended immunizations for AHS Healthcare workers and/or
3. test results related to screening for Tuberculosis as recommended for AHS Healthcare workers.
This information will be added to your Workplace Health and Safety record. A complete list of the
recommended immunizations is provided on page 2.
For questions, concerns or more information about the collection, use or disclosure of your personal or health
information, for the purposes described above, please contact the OHN in your area. Contact information is
available on page 3 and is also available on Insite: http://insite.albertahealthservices.ca/1237.asp.
18226 (Rev2015-10)
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Communicable Disease Assessment
Last Name
Given Name
Other Name(s) (if applicable)
Birth date (yyyy-Mon-dd)
Primary Contact Number
Personal Health Number (PHN)
Alternate Contact Number Personal Email
Home Address
City
Province
Postal Code
AHS Employee # /CPSA # (if available) Start date (yyyy-Mon-dd) Title/Position
Department
AHS Site/Facility
AHS Zone
Name of AHS Manager/Department Head
Have you been previously employed by AHS or any of its former entities?
Dates of service (from/to)
No
Yes
Complete this information
Location/Facility
Communicable Disease History
Have you ever had Varicella (Chicken Pox or Shingles) (as diagnosed by a healthcare provider or by a strong
personal history as evidenced by visible scars, strong recollection of disease, history of shingles, Health Care
Workers (HCW’s) children have had the disease and HCW didn’t get it)?
Yes
No
Unsure
If yes, at what age?
Immunization Status (Include a copy of your current immunization records)
If you do not have your records, you may be able to obtain them from the following:
 Alberta Public Health (if you received your vaccinations in AB)
 Health agency where you received your vaccinations
 Your previous education facility
 Your previous employer/healthcare employer
 Your physician
Attach all immunization and blood test results for the following (if applicable)
(A titre is a blood test that measures antibodies in your body against a virus)
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Measles/Mumps/Rubella(MMR)Immunization
 Measles titre results
 Rubella titre results
Varicella(ChickenPox)Immunization
 Varicella titre results
Pertussis (Whooping Cough)(dTap or Tdap)
Immunization
Hepatitis B Immunization
 Hepatitis B antibody titre results
For WHS Office Use Only
OHN Name (please print)
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Tetanus Diphtheria (Td) Immunization
Polio Immunization
Most recent skin test for Tuberculosis
For Laboratory Workers
 Meningococcal Immunization
 Typhoid Immunization
OHN Signature
Date (yyyy-Mon-dd)
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Communicable Disease Assessment
Workplace Health and Safety Contact Information
ZONE
Contact Information
NORTH
North Zone OHN, Alberta Health Services
North Zone Workplace Health and Safety
Westlock Administration Office
9732-100 Avenue
Westlock, AB, T7P 2G3
Phone 780-350-3166
Email [email protected]
Fax
403-476-9622
CALGARY
Workplace Health and Safety OHN
Calgary Zone Workplace Health and Safety
Cubicle 8246, 10301 Southport Road SW
Calgary, AB, T2W 1S7
Phone 403-955-2900
Email [email protected]
Fax
403-476-8759
EDMONTON Workplace Health and Safety OHN
Workplace Health and Safety Edmonton Zone Workplace
Health & Safety Services
12R01, R Wing, 11111 Jasper Avenue
Edmonton, AB, T5K 0L4
Note: This is a mailing address only.
Do not bring your CDA form to this location.
Phone: 780 342-8555
Email: [email protected]
Fax: 780 342-8448
SOUTH
South Zone Workplace Health and Safety OHN
Room 4K-138, Chinook Regional Hospital
960 19 Street South
Lethbridge, AB, T1J 1W5
Phone 403-388-6104 Option 2
[email protected]
Instructions
Fax or email your completed form.
Your designated OHN will contact
you after receiving your form.
Fax or email your completed form.
You will be contacted by WHS to
arrange an appointment if required.
Fax or email your completed form.
You will be contacted by WHS to
arrange an appointment if required.
Fax or email your completed form.
Call or email us to arrange your
assessment.
South West:
Fax 403-388-6018
Phone 403-388-6104 Option 2
CENTRAL
South East:
Fax 403-502-8286
Phone 403-528-8103 Option 0
Central Zone Workplace Health and Safety OHN
Red Deer Regional Hospital Centre
Workplace Health & Safety – Central Zone
3rd Floor South Complex, 3942-50A Ave
Red Deer, AB, T4N6R2
403-343-4620 ext 3 or Toll-Free1-888-343-4620 ext 3
Email [email protected]
Fax
403-343-4697
18226 (Rev2015-10)
Fax or email your completed form.
WHS will contact you after receiving
your form.
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