Miscellaneous
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Pre-placement
Title: [text name="variable_1" default="sample text"]
Work Group: [text name="variable_2" default="sample text"]
Start Date: [date name="variable_3" default="11/23/2021"]
___________________________________________________________
Immunizations:
MMR: [checkbox name="variable_1" value="not required|vaccine x 2|hx of pos titer|titers today|administered today"]
Varicella: [checkbox name="variable_2" value="not required|vaccine x 2|hx of pos titer|titers today|administered today"]
Hep B: [checkbox name="variable_3" value="not required|vaccine x 3|hx of pos titer|titer today|other"]
Tdap: [checkbox name="variable_4" value="UTD|last immunization >10 years|administered today|other"]
Flu: [checkbox name="variable_5" value="UTD|administered today|other"]

COVID: [checkbox name="variable_6" value="Moderna x2|Pfizer x 2|J&J x1|other"]
TB: [checkbox name="variable_7" value="proof of IGRA w/i 90 doh|IGRA today|hx of pos TST|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"]
Respiratory Baseline Questionnaire: [checkbox name="variable_10" value="not required|clear|not clear"]
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|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 hospitalizations, chronic diseases, and need for accommodations at work."]
___________________________________________________________
Needs: [textarea name="variable_18" default=" none"]
OHS clearance: [checkbox name="variable_19" value="clear|pending|clear for badge|on hold"]
Pre-placement
Title:
Work Group:
Start Date:
___________________________________________________________
Immunizations:
MMR:
Varicella:
Hep B:
Tdap:
Flu:

COVID:
TB:
___________________________________________________________
Ishihara Color Test:
Arch Baseline Questionnaire:
Respiratory Baseline Questionnaire:
FIT test:
___________________________________________________________
Medications:
Allergies:
PMH:
___________________________________________________________
Needs:
OHS clearance:

Result - Copy and paste this output:
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