Employee Health Forms

The following forms must be used by employees, volunteers and affiliates to manage medical information. An explanation of the proper use of each form is provided. However, if there are questions about which form to use, contact the Health office for further explanation to avoid completing and submitting the incorrect form.

Forms specific for students should be accessed on the Student Health website. If you have difficulty accessing any of the forms below, please contact:
Jane Bennett, MSN, NP,
Assistant Director
bennetja@upstate.edu
315 464-4260

Medical History/Physical Exam

All new staff (employees and volunteers) must complete the medical history form and undergo a physical exam. The physical exam is performed at the Health Office with the following exceptions. Volunteers, incoming residents and professional staff may submit an exam from their private provider.

  • Medical History PDF document
    All employees must complete the first three pages pertaining to personal medical history.
  • Allergy History PDF document
    All employees must complete this form to document pre-existing allergies, including latex.

Health Clearance for Non-Employees and Affiliates

All non-employees (personnel not on an Upstate payroll) and affiliates, with potential for patient contact, must be screened for health impairment that may be detrimental to Upstate patients and/or other personnel. This is accomplished by completing the following Certificate of Health form and submitting it to the Employee/Student Health Office.

Please note the following guidelines:

  • All non-employees who will be visiting either Upstate campus for 3 days or less in any month with minimal patient contact should fill out this form through Section 1. A signature is required by the applicant. Appropriate users include vendors, insurance company representatives, observers and those engaged in career shadowing activities that fit the above criteria. (NOTE: This form replaces the old Short-term Health Statement)
  • All non-employees who will be visiting either Upstate campus whose activity exceeds 3 days and is conducted in an area (building) where patient care takes place should fill out the entire form through Section 2. A signature is required by the applicant and a primary care provider. Copies of lab work are required. Appropriate users include visiting students, visiting medical personnel, medical interpreters and temporary agency non-clinical personnel. (NOTE: This form replaces both the Detailed Health Statement and the old Certificate of Health)
  • Certificate of Health PDF document


Annual Health Assessments

In accordance with the New York State Health Code, Section 405.3, the health status of each employee, volunteer, student and affiliate is reassessed as frequently as necessary, but no less than annually, to ensure personnel are free from health impairments which pose potential risk to patients or personnel, or which may interfere with the performance of duties.

Annual Health Assessments (AHA's) provide us with the knowledge of any changes to your health status that have occurred in the preceding year. AHA’s consist of a health and wellness screening, tuberculin skin testing (if required), Mask-fit testing (if required), and updates to your Tetanus/Diphtheria immunization. These are done on a walk-in basis – no appointment is necessary. Please Note: AHA's cannot be done on Thursdays if a tuberculin skin test is required.

Respiratory Protection Clearance

All incoming residents and employees providing direct patient care in respiratory isolation need to complete this form for review by health office staff. When medical clearance is completed, the employee will be mask fitted by Employee Student Health or Environmental Health & Safety.

Release of Medical Information

All transfer of personal medical information must be initiated by the use of a release of information form in an effort to preserve confidentiality, to comply with HIPPA regulations and to maintain a record of the information transfer.