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Alora/EVV
Alora
EVV
Home
About
Services
Skilled Services
Nursing Services
Wound Care
Ostomy Care
Catheter Care
G-Tube Feeding
Vital Signs Monitoring And Report To PCP Doctor
Safety Supervision
Symptom Monitoring
Mobility Support
Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Implement Short/long term planning of care
Physical Therapy
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Balancing & Gait
Create an exercise plan
Occupational Therapy
Restore Function
Promote ADL functions
Non-Skilled Services
Home Health Aide
Medication reminders
Vital signs monitoring & Report to Clinical Nurse
Mobility support
Forms
Administrator Competency & Job Description Form
Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
Resources
Employement
Alora/EVV
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EVV
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Employee Tuberculosis
Employee Tuberculosis
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Download
Employee Tuberculosis
or fill out the form below
Employee Tuberculosis
1. Are you from or have you lived for two months or more in Africa, Asia, Central or South America, or Eastern Europe?
No
Yes
List countries
(Required)
2. Have you been diagnosed with a chronic condition that may impair your immune system?
No
Yes
(Required)
Chronic steroid use
HIV infection
Cancer of the head or neck
Silicosis
Leukemia
Gastrectomy/intestinal bypass
Crohn’s disease
Rheumatoid arthritis
Use of TNF-α antagonist
Lymphoma
Other
Diabetes mellitus
Dialysis/Renal failure
Chronic malabsorption syndromes
Low body weight
Hodgkin’s Disease
Other
3. Have you ever resided, worked or volunteered in any of the following facilities?
No
Yes
Prison
Homeless shelter
Hospital
Other long term treatment cente
Nursing home
4. Do you currently have any of the following symptoms?
No
Yes
Cough > 3 weeks
Productive cough
Coughing up blood
Unexplained fever
Night sweats
Unexplained wt. loss
Chest pain
Shortness of breath
Fatigue
Chills
Loss of appetite
Weakness
5. Have you ever had contact with a person known to have active tuberculosis?
No
Yes
6. Have you ever used injection drugs?
No
Yes
7. Have you had a tuberculin skin test before?
No
Yes
Where given
(Required)
Date
(Required)
MM slash DD slash YYYY
File
Max. file size: 32 MB.
8. Have you had a tuberculin skin test before?
No
Yes
Where given
(Required)
Date
(Required)
MM slash DD slash YYYY
File
Max. file size: 32 MB.
The information above is true and complete, and I am aware that deliberate misrepresentation may jeopardize my health. I understand that this information is confidential and will not be released without my knowledge and written permission.
Applicant / Employee Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
The information above is true and complete, and I am aware that deliberate misrepresentation may jeopardize my health. I understand that this information is confidential and will not be released without my knowledge and written permission.
Referred to MD?
(Required)
No
Yes
cleared to work?
No
Yes
Date
(Required)
MM slash DD slash YYYY
File
(Required)
Max. file size: 32 MB.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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Home
About
Services
Skilled Services
Nursing Services
Wound Care
Ostomy Care
Catheter Care
G-Tube Feeding
Vital Signs Monitoring And Report To PCP Doctor
Safety Supervision
Symptom Monitoring
Mobility Support
Speech Therapy
Evaluation/Diagnosis/Prevention of speech impairment
Swallow evaluation and management
Cognitive communication
Medical Social Worker
Providing adequate resources for clients in the community
Implement Short/long term planning of care
Physical Therapy
Improve Mobility & Strength
Aid inside/outside ambulation
Range of motion, Positioning & Transfers
Balancing & Gait
Create an exercise plan
Occupational Therapy
Restore Function
Promote ADL functions
Non-Skilled Services
Home Health Aide
Medication reminders
Vital signs monitoring & Report to Clinical Nurse
Mobility support
Forms
Administrator Competency & Job Description Form
Clinical Manager Job Description Form
Home Health Aide Competency & Job Description & Skill Validation
LPN Competency Job Description Form
MSW Competency Job Description Form
Occupational Therapist Assistant Job Description Form
Occupational Therapist Job Description Form
Physical Therapist Assistant Job Description Form
Physical Therapist Job Description Form
RN Job Description & Performance Evaluation & Competency Form
Speech Therapist Job Description Form
Resources
Employement
Alora/EVV
Alora
EVV
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