Education

Name

 

Address-City, State

Graduated?

Degree or Major

High School

College

Other

Previous Employment. Please list at least three employers.

1)

2)

3)

Reference Check

Please do not include your relatives as references

1)

2)

3)

TB Symptom Screening

Have you had any of the following symptoms within the past year?

EMPLOYEE TB SCREENING ACKNOWLEDGMENT

HEPATITIS B VACCINE
REQUEST/REFUSAL FORM

I have received instruction concerning the risk of exposure to Hepatitis B as a health care worker. I have also been instructed in Universal Precautions and other safety measures that will prevent contracting this virus

I understand that although there are risks associated with the Hepatitis B Vaccine, it does reduce the risk of serious disease should exposure to the Hepatitis B Virus occur.

I hereby elect to receive the Hepatitis B Vaccine series

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.

Please answer the following questions:

I have read and understand Romeos Staffing Agency confidentiality policy.

I have read and understand Romeos Staffing Agency confidentiality policy.

CONFLICT OF INTEREST DISCLOSURE FORM

I

have reviewed the Conflict-of-Interest Policy of Romeos Staffing Agency and understand its Contents. I have no current or potential associations, relationships, or circumstances, that Conflict with this organization. (You may list any situations of which you are uncertain.