MD PrePlacement

[checkbox name="variable_20" value="MD    Preplacement    -    Chart    Review"]
[textarea name="variable_21" default=""]
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Immunizations:
MMR: [checkbox name="variable_1" value="not required|not    provided|vaccine x 2|hx of pos titer|other"]
Varicella: [checkbox name="variable_2" value="not required|not    provided|vaccine x 2|hx of pos titer"]
Hep B: [checkbox name="variable_3" value="vaccine x 3|hx of pos titer|not    required|not    provided |   other"]
[text name="variable_22" default=""]
Tdap: [checkbox name="variable_4" value="UTD|last    immunization    >10years    ago|not    provided |  other"]
Flu: [checkbox name="variable_5" value="UTD|not    provided |   not    required    -    outside    flu    season|other"]
COVID: [checkbox name="variable_6" value="Received seasonal COVID vaccine ’23-‘24|Approved Medical or Religious Exemption|Not required- outside of COVID vaccine ’23-’24 season|not    provided |other"]
TB: [checkbox name="variable_7" value="proof of    negative    IGRA w/i 90 doh|hx    of    2step    PPD,    most    recent    within    90    doh |hx of pos TST or IGRA|proof of neg CXR|Negative    TBSA    as    of    today   |not    provided |other"]
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Arch Baseline Questionnaire: [checkbox name="variable_8" value="not required|clear|working with large animals, Q-fever required"]
[text name="variable_9" default=""]
Respiratory Baseline Questionnaire: [checkbox name="variable_10" value="not required|not    provided |clear|not clear"]
[text name="variable_11" default=""]
FIT test:   [checkbox name="variable_12" value="will    need    fit    testing    on-site|other"]
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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."]
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Needs: [textarea name="variable_18" default=" "]
OHS clearance: [checkbox name="variable_19" value="clear|pending|on hold"]