Work Clearance Form

HAWAII PACIFIC HEALTH Work Clearance Form

Please complete the following return to work form, we ask that you provide accurate responses. At the end of completion, you will either receive a clearance or a denial to return to work. If at any point you have questions or need assistance, you may call the Employee Health return to work line at (808) 529-4905 from 6:30a-3p M-F or the house supervisor after hours, on weekends and holidays.

PERSONAL INFORMATION (Please provide the following information):

First name: Last name: Date of birth: Employee ID: Facility: Independent Medical Provider Kapiolani Medical Center for Women & Children Kauai Medical Clinic Pali Momi Medical Center Straub Medical Center Wilcox Medical Center Other

Other facility name:

Department: Role/Job title: Supervisor/Manager: Employee phone/cell # (Must include area code): Email:

Are you completing this work clearance form as a part of the regular, every week COVID testing requirement because you are not vaccinated?

Yes No

Do you attest to having a negative COVID-19 screening test within the last 7 days of reporting to work?

Yes No

What was the date of your COVID-19 screening test?

Did you test within HPH?

Yes No

Dates you were out from work:

Start Date: End Date:

Next scheduled date to work:

Please answer the following questions:

1. Have you experienced any symptoms of illness in the past 24 hours?

Yes No

1a. What symptoms are you currently experiencing? Check all that apply

Headache Fever Fatigue Sore throat Cough Runny/stuffy nose Body aches Diarrhea Nausea or vomiting Other

Other, specify:

1b. What was the date of onset of symptoms?

1c. Have your symptoms resolved or are mild and improving?

Yes No

2. Were you out from work due to any of the following conditions? check all that apply

Wound Surgery Monkey pox Conjunctivitis (pink eye) Shingles Hand, foot, and mouth disease Herpes simplex (cold sore) Hepatitis A Mumps Meningococcal disease Strep infection Rubella (German measles) Pertussis Varicella (Chicken pox) Measles Pediculosis (Head lice) Scabies Tuberculosis Skin infection NONE OF THE ABOVE

3. Are you planning to return to work with an assistive device (cane, crutches, wheelchair, scooter, walker, brace, cast)?

Yes No

4. Is your absence COVID-19 related?

Yes No Unsure

4a. Are you fully vaccinated for COVID-19?

Yes No

4b. Is there anyone in your household that has tested positive for COVID in the last 2 weeks?

Yes No

4c. Have you recently taken a covid test?

Yes No

4d. Have you recently tested positive for COVID 19?

Yes No

4d1. What was date of your COVID-19 test? 4d2. What was the last day you were at work?

4d3. Did you experience symptoms?

Yes No

If yes, what was the date of onset of symptoms?

4d4. Have you received your booster vaccine?

Yes No

4d5. Have you been isolated for more than 5 days from the onset of symptoms or positive COVID test and have improving symptoms?

Yes No

5. Have you been out of work due to an illness or injury for more than 14 days?

Yes No

6. Were you absent because of an injury?

Yes No

6a. Do you have physician clearance to return to work?

Yes No

6b. Do you have any work restrictions?

Yes No

7. Are you working with Human Resources/Benefits for a Leave of Absence?

Yes No

7a. Do you have physician clearance to return to work?

Yes No

8. Do you feel well enough to return to work?

Yes No