Duluth Care
Employee
Date
The above name employee has been informed of the signs and symptoms of Tuberculosis (TB) and Hepatitis. Symptoms such as elevaved temperature, fatigue, weight loss, coughing, nauses and vomiting abdominal pain should be reported to the nursing agency immediately. An employee's exposure to TB or Hepatitis, may put the client in danger of becoming infected with TB or Hepatitis.
The above named employee has been informed that he/she must report if they have had any exposure to tuberculosis or Hepatitis at any time.
For TB surveillance, the employee must get TB testing yearly or symptom screening or a chest X-ray if indicated.
To report an exposure, the employee will inform the nursing agency promptly, immediately on becoming aware of an exposure.
By signing this document, the employee is aware of the need to report any such exposure to TB or Hepatitis.
Signature of Employee:
Signature of Administrator or Designee:
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