Title: [text name="variable_1" default=""]
Work Group: [text name="variable_2" default=""]
Start Date: [date name="variable_3" default=""]
MMR: [checkbox name="variable_1" value="not required|vaccine x 2|hx of pos titer|titers today|administered today - VIS reviewed, consent signed|other"]
Varicella: [checkbox name="variable_2" value="not required|vaccine x 2|hx of pos titer|titer today|administered today - VIS reviewed, consent signed|other"]
Hep B: [checkbox name="variable_3" value="not required|vaccine x 3|administered today - VIS reviewed, consent signed|hx of pos titer|titer today|other"]
[text name="variable_22" default=""]
Tdap: [checkbox name="variable_4" value="UTD|last immunization >10 years|declined updated booster today, meets BCH requirements for Tdap|administered today - VIS reviewed, consent signed|other"]
Flu: [checkbox name="variable_5" value="UTD|VIS reviewed, consent signed, administered today|on hold until confirmed fully remote by HR|has not received most updated vaccine, due date 11/17|other"]
COVID: [checkbox name="variable_6" value="COVID '23-24 x1|has not received most updated vaccine, due date 11/17|Novavax x3|reports not required due to fully remote work status, on hold until confirmed by HR|other"]
TB: [checkbox name="variable_7" value="proof of IGRA w/i 90 doh|IGRA today|hx of pos TST or IGRA|proof of neg CXR|other"]
Ishihara Color Test: [checkbox name="variable_8" value="not required|normal exam|abnormal exam"]
Arch Baseline Questionnaire: [checkbox name="variable_9" value="not required|clear|working with large animals, Q-fever required"]
[text name="variable_4" default=""]
Respiratory Baseline Questionnaire: [checkbox name="variable_10" value="not required|clear|not clear"]
[text name="variable_5" default=""]
FIT test: [checkbox name="variable_11" value="not required|passed with Prestige Regular|passed with Prestige small|passed with 3M small|passed with 3M Regular|failed, educated on PAPR usage|other|Provided qualitative fit testing using bitrex or saccharin in compliance with NFPA 1500, NFPA 1404, ANSI Z88.5, ANSI Z88.21992, OSHA CRF 1910.134, and CCR Title 8 Sec. 5144. Annual respirator training provided on why the respirator is necessary and how improper fit, use or maintenance can compromise its protective effect; limitations and capabilities of the respirator; effective use in emergency situations; how to inspect, put on and remove, use and check the seals; maintenance and storage; and recognition of medical signs and symptoms that may limit or prevent effective use.
Medications: [textarea name="variable_13" default=" none"]
Allergies: [textarea name="variable_15" default=" denies"]
PMH: [textarea name="variable_17" default=" No significant health/physical issues noted. Denies need for accommodations at work."]
Needs: [textarea name="variable_18" default=" "]
OHS clearance: [checkbox name="variable_19" value="clear|pending|clear for badge|on hold"]
Work Group:
Start Date:
Hep B:

Ishihara Color Test:
Arch Baseline Questionnaire:

Respiratory Baseline Questionnaire:

FIT test:




OHS clearance:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.59, 22 form elements, 32 boilerplate words, 5 text boxes, 4 text areas, 1 dates, 12 checkboxes, 69 total clicks
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