verification->chrc)) { echo $nurse->verification->chrc; } ?>' data-error="Please enter a file name.">

verification->finger_print=='1') { echo "checked"; } ?> > Yes

verification->live_with_patient=='0') { echo "checked"; } ?> > No

verification->submission_date)) { echo $nurse->verification->submission_date; } ?>' required data-error="Please enter a submission date.">

verification->results_receive_date)) { echo $nurse->verification->results_receive_date; } ?>' placeholder="" required data-error="Please enter Results Received Date.">

verification->nysid)) { echo $nurse->verification->nysid; } ?>' placeholder="" required data-error="Please enter nysid.">

verification->second_submission_date)) { echo $nurse->verification->second_submission_date; } ?>' >

verification->second_results_receive_date)) { echo $nurse->verification->second_results_receive_date; } ?>' placeholder="" >

verification->second_nysid)) { echo $nurse->verification->second_nysid; } ?>' placeholder="" >

verification->third_submission_date)) { echo $nurse->verification->third_submission_date; } ?>' >

verification->third_results_receive_date)) { echo $nurse->verification->third_results_receive_date; } ?>' placeholder="" >

verification->third_nysid)) { echo $nurse->verification->third_nysid; } ?>' placeholder="" >

state1 =='NY'){ if($nurse->qualification_type == 4 || $nurse->qualification_type == 5){ ?>

verification->state_lic_no)) { echo $nurse->verification->state_lic_no; } ?>' required data-error="Please enter State Licenses Number.">

verification->state_lic_exp)) { echo $nurse->verification->state_lic_exp; } ?>' required data-error="Please enter State Licenses Number.">

qualification_type == '6' || $nurse->qualification_type == '7'){ ?>

verification->state_reg_check)) { echo $nurse->verification->state_reg_check; } ?>' placeholder="" required data-error="Please enter NY State Registry Check.">

qualification_type == '4' || $nurse->qualification_type -= '5'){ ?>

verification->state_verification)) { echo $nurse->verification->state_verification; } ?>' placeholder="" required data-error="Please enter NY State Verification.">

qualification_type == '4' || $nurse->qualification_type -= '5'){ ?>

verification->npi_no)) { echo $nurse->verification->npi_no; } ?>' minlength="10" maxlength="10" placeholder="" onkeypress="return isNumberKey(event)" required data-error="Please enter npi.">

verification->malpractice_insurence)) { echo $nurse->verification->malpractice_insurence; } ?>' placeholder="" required data-error="Please enter Malpractice Insurance Policy.">

verification->carrier)) { echo $nurse->verification->carrier; } ?>' placeholder="" required data-error="Please enter Carrier name.">

verification->policy_no)) { echo $nurse->verification->policy_no; } ?>' placeholder="" required data-error="Please enter Auto Policy.">

verification->exp_date)) { echo $nurse->verification->exp_date; } ?>' placeholder="" required data-error="Please enter Expiration Date.">

verification->automobile_insurence_policy)) { echo $nurse->verification->automobile_insurence_policy; } ?>' placeholder="" required data-error="Please enter Automobile Insurance Policy.">

qualification_type == '4' || $nurse->qualification_type -= '5'){ ?>

verification->cpr_certification)) { echo $nurse->verification->cpr_certification; } ?>' placeholder="" required data-error="Please enter CPR Certification (Expiration Date).">

verification->aditional_certification)) { echo $nurse->verification->aditional_certification; } ?>' placeholder="" required data-error="Additional Certifications.">

verification->omig=='1') { echo "checked"; } ?> > Employable

verification->omig=='0') { echo "checked"; } ?> > Cannot Employ

verification->notes)) { echo $nurse->verification->notes; } ?>' placeholder="" required data-error="notes">

physical_exam_form) ?>

height_feet)) $height=explode('/', $physical_exam_form->height_feet); else $height=''; // if(!empty($physical_exam_form->height_inches)) // $height_inches=explode('/', $physical_exam_form->height_inches); // else // $height_inches=''; ?>

Test Date

Result in mm

Result Date

PPD (Mantoux)

PPD (Mantoux) 2nd

X-Ray if positive PPD

Rubella Titre

Rubeola Titre (If born after 11/1/57 Rubeola verified)

Influenza Vaccine Site:

-Lot Number:

Expiration

Dates(s)

Diphtheria

Tetanus

Mumps

Rubella Vaccine

Measles Vaccine

HB Vaccine

Drug Screen:

eyeglasses==1) { echo "checked"; } ?>> Yes

eyeglasses==0) { echo "checked"; } ?>> No

hearingAid==1) { echo "checked"; } ?>> Yes

hearingAid==0) { echo "checked"; } ?>> No

extended_periods==1) { echo "checked"; } ?>> Yes

extended_periods==0) { echo "checked"; } ?>> No

extended_periods_explain)) { echo $physical_exam_form->extended_periods_explain; } ?>' placeholder="">

disorders==1) { echo "checked"; } ?>> Yes

disorders==0) { echo "checked"; } ?>> No

extended_periods_explain)) { echo $physical_exam_form->extended_periods_explain; } ?>' placeholder="">

emp_health_assesment) ?>

Emergency_Contact_Relationship)) { if ($nurse->Emergency_Contact_Relationship == $val->id) { $rel= $val->name; } } }?>

Emergency_Contact_zipcode; } ?>' disabled>

Indicate if you are suffering from or have a history of the following conditions:

Condition	Yes	No
DIABETES	diabetes==1) { echo "checked"; } ?>/>	diabetes==0) { echo "checked"; } ?>/>
KIDNEY DISEASE	kidney_disease==1) { echo "checked"; } ?>/>	kidney_disease==0) { echo "checked"; } ?>/>
HEART DISEASE	heart_disease==1) { echo "checked"; } ?>/>	heart_disease==0) { echo "checked"; } ?>/>
HIGH BLOOD PRESSURE	high_blood_pressure==1) { echo "checked"; } ?>/>	high_blood_pressure==0) { echo "checked"; } ?>/>
ARTHRITIS	arthritis==1) { echo "checked"; } ?>/>	arthritis==0) { echo "checked"; } ?>/>
MENTAL ILLNESS	mental_illness==1) { echo "checked"; } ?>/>	mental_illness==0) { echo "checked"; } ?>/>
EPILEPSY/CONVULSIONS	epilepsy==1) { echo "checked"; } ?>/>	epilepsy==0) { echo "checked"; } ?>/>
SWELLING IN THE EXTREMITIES	swelling_extremities==1) { echo "checked"; } ?>/>	swelling_extremities==0) { echo "checked"; } ?>/>
ALLERGIES	allergies==1) { echo "checked"; } ?>/>	allergies==0) { echo "checked"; } ?>/>

Condition	Yes	No
BACK PAIN	back_pain==1) { echo "checked"; } ?>/>	back_pain==0) { echo "checked"; } ?>/>
PAIN ON URINATION	pain_urination==1) { echo "checked"; } ?>/>	pain_urination==0) { echo "checked"; } ?>/>
CHANGE IN BOWEL HABITS	change_bowel_habit==1) { echo "checked"; } ?>/>	change_bowel_habit==0) { echo "checked"; } ?>/>
INCREASED THIRST	increased_thirst==1) { echo "checked"; } ?>/>	increased_thirst==0) { echo "checked"; } ?>/>
PERSISTENT SORES/LUMPS	persistent_lumps==1) { echo "checked"; } ?>/>	persistent_lumps==0) { echo "checked"; } ?>/>
INFECTIOUS DISEASE	infectious_disease==1) { echo "checked"; } ?>/>	infectious_disease==0) { echo "checked"; } ?>/>
CANCER	cancer==1) { echo "checked"; } ?>/>	cancer==0) { echo "checked"; } ?>/>
ANY OTHER PHYSICAL DISABILITY	other_disability==1) { echo "checked"; } ?>/>	other_disability==0) { echo "checked"; } ?>/>

TURBERCULOSIS QUESTIONNAIRE
Indicate if you have been experiencing the following conditions:

Condition	Yes	No
PERSISTENT COUGH FOR < 3 WEEKS	cough_3_weeks==1) { echo "checked"; } ?>/>	cough_3_weeks==0) { echo "checked"; } ?>/>
BLOOD IN THE SPUTUM	blood_sputum==1) { echo "checked"; } ?>/>	blood_sputum==0) { echo "checked"; } ?>/>
SHORTNESS OF BREATH	shortness_breath==1) { echo "checked"; } ?>/>	shortness_breath==0) { echo "checked"; } ?>/>
NIGHT SWEATS	night_sweat==1) { echo "checked"; } ?>/>	night_sweat==0) { echo "checked"; } ?>/>
CHEST PAIN	chest_pain==1) { echo "checked"; } ?>/>	chest_pain==0) { echo "checked"; } ?>/>

Condition	Yes	No
UNEXPLAINED WEIGHT LOSS	unexplained_weight_loss==1) { echo "checked"; } ?>/>	unexplained_weight_loss==0) { echo "checked"; } ?>/>
LOSS OF APPETITE	appetite_loss==1) { echo "checked"; } ?>/>	appetite_loss==0) { echo "checked"; } ?>/>
HOARSENESS	hoarseness==1) { echo "checked"; } ?>/>	hoarseness==0) { echo "checked"; } ?>/>
INCREASED THIRST	thirst_increase==1) { echo "checked"; } ?>/>	thirst_increase==0) { echo "checked"; } ?>/>
FATIGUE	fatigue==1) { echo "checked"; } ?>/>	fatigue==0) { echo "checked"; } ?>/>
FEVER	fever==1) { echo "checked"; } ?>/>	fever==0) { echo "checked"; } ?>/>

positive_ppd==1) { echo "checked"; } ?>> Yes

positive_ppd==0) { echo "checked"; } ?>> No

positive_ppd ==0 ) {?> style="display:none" > ppd_explain)) { echo $emp_health_assesment->ppd_explain; } ?>' placeholder="">

under_care==1) { echo "checked"; } ?>> Yes

under_care==0) { echo "checked"; } ?>> No

under_care ==0 ) {?> style="display:none" > under_care_explain)) { echo $emp_health_assesment->under_care_explain; } ?>' placeholder="">

change_behaviour==1) { echo "checked"; } ?>> Yes

change_behaviour==0) { echo "checked"; } ?>> No

change_behaviour ==0 ) {?> style="display:none" > change_behaviour_explain)) { echo $emp_health_assesment->change_behaviour_explain; } ?>' placeholder="">

prescription_medications==1) { echo "checked"; } ?>> Yes

prescription_medications==0) { echo "checked"; } ?>> No

prescription_medications ==0 ) {?> style="display:none" > prescription_medications_explain)) { echo $emp_health_assesment->prescription_medications_explain; } ?>' placeholder="">

screening_test==1) { echo "checked"; } ?>> Yes

screening_test==0) { echo "checked"; } ?>> No

screening_test ==0 ) {?> style="display:none" > screening_test_explain)) { echo $emp_health_assesment->screening_test_explain; } ?>' placeholder="">

past_illness==1) { echo "checked"; } ?>> Yes

past_illness==0) { echo "checked"; } ?>> No

past_illness ==0 ) {?> style="display:none" > past_illness_explain)) { echo $emp_health_assesment->past_illness_explain; } ?>' placeholder="">

name_of_physician)) { echo $emp_health_assesment->name_of_physician; } ?>' placeholder="">

tel_of_physician)) { echo $emp_health_assesment->tel_of_physician; } ?>' placeholder="">

hb_form); //pr($nurse);die; ?>

I fname." ".$nurse->mid_name." ".$nurse->lname ?> , have been informed of the complication / side effects of receiving Hepatitis B vaccine and I choose to have the vaccine administered to me.

incident_report==1) { echo "checked"; } ?>> Yes

incident_report==0) { echo "checked"; } ?>> No

report_completed==1) { echo "checked"; } ?>> Yes

report_completed==0) { echo "checked"; } ?>> No

Hepatitis B Vaccine	TYPE	DATE	DOSE	SITE
Initial Dose
Second Dose
Third Dose
Booster Dose

DATE	TYPE	RESULTS	ACTION TAKEN

Field	Data	Action
Basic Info
Name	fname.''.$nurse->lname; ?>
Mobile Number	phone; ?>	<?php echo $nurse->phone; ?>
Email	email; ?>	<?php echo $nurse->email; ?>
Qualification type	qualification; ?>	<?php echo $nurse->qualification; ?>
Total years of experience	years_of_exp; ?>	<?php echo $nurse->years_of_exp; ?>
Personal Info
Gender	gender; ?>
Marital Status	marital_status; ?>
Dependents	dependents; ?>	<?php echo $nurse->dependents; ?>
Date of Birth	dob; ?>	<?php echo $nurse->dob; ?>
Soc Sec	soc_sec; ?>	<?php echo $nurse->soc_sec; ?>
Country of Birth	country_of_birth; ?>	<?php echo $nurse->country_of_birth; ?>
Ethnicity	ethnicity; ?>	<?php echo $nurse->ethnicity; ?>
Height (feet/inches)	height; ?>
Weight ()	weight; ?>
Eye Color	eye_color; ?>
Hair Color	hair_color; ?>
Primary Languages Spoke	primary_langualge; ?>
Contact Info
Permanent Address	address1.','.$nurse->direction1.','.$nurse->state1_name.','.$nurse->county1.','.$nurse->zipcode1; ?>	<?php echo $nurse->address1.','.$nurse->direction1.','.$nurse->state1_name.','.$nurse->county1.','.$nurse->zipcode1; ?>
State Verification	state1_name; ?>
Alternate Mailing Address	address2.','.$nurse->direction2.','.$nurse->state2_name.','.$nurse->county2.','.$nurse->zipcode2; ?>	<?php echo $nurse->address2.','.$nurse->direction2.','.$nurse->state2_name.','.$nurse->county2.','.$nurse->zipcode2; ?>
Alternative Mobile No.	phone2; ?>	<?php echo $nurse->phone2; ?>
Other Contact	other_contact; ?>	<?php echo $nurse->other_contact; ?>
Alternative Email	alternative_email; ?>	<?php echo $nurse->alternative_email; ?>
Preferred Contact Method	preferred_contact; ?>	<?php echo $nurse->preferred_contact; ?>
Basic Documents
School Certificate Verification
Photo	View	<?php echo $documentsrem[_DOC_PHOTOCODE_][0]; ?>
Citizen Documentation	View	<?php echo $documentsrem[_DOC_CTZCODE_][0]; ?>
Social Security Card	View	<?php echo $documentsrem[_DOC_SSCCODE_][0]; ?>
State or Federal issued ID	View	<?php echo $documentsrem[_DOC_SFICODE_][0]; ?>
Malpractice Insurance Policy	View	<?php echo $documentsrem[_DOC_MICCODE_][0]; ?>
Resume	View	<?php echo $documentsrem[_DOC_RESUMECODE_][0]; ?>
NPI Document	View	<?php echo $documentsrem[_DOC_NPICODE_][0]; ?>
Medical Documents
Annual Employee Health	View	<?php echo $documentsrem[_DOC_EHA_CODE_][0]; ?>
Drug Screen	View	<?php echo $documentsrem[_DOC_DRUG_SCREENINGCODE_][0]; ?>
Flu Vaccine	View	<?php echo $documentsrem[_DOC_FLU_VACCINECODE_][0]; ?>
Covid Report	View	<?php echo $documentsrem[_DOC_COVID_][0]; ?>
CPR Report	View	<?php echo $documentsrem[_DOC_CPR_][0]; ?>
Licenses & Certifications
Licence	View	<?php echo $documentsrem[_DOC_TRAINING_LICENCE_][0]; ?>
Aditional Documents	View	<?php echo $documentsrem[_DOC_TRAININGCODE_][$i]; ?>
Other Documents
Documents Details	View	<?php echo $documentsrem[_DOC_OTHERCODE_][$i]; ?>
Employment Info
Availability(Borough)	avail_borough; ?>	<?php echo $nurse->avail_borough; ?>
Availability(Time Slot)	avail_time_slot; ?>	<?php echo $nurse->avail_time_slot; ?>
Availability(Stay)	availability_stay; ?>	<?php echo $nurse->availability_stay; ?>
Application Date	application_date; ?>
Pre Employment Skill Competency	pre_emp_skill; ?>	<?php echo $nurse->pre_emp_skill; ?>
PCA Registry Number	PCA_Registry_Number; ?>	<?php echo $nurse->PCA_Registry_Number; ?>
Reference
Personal References Name	Personal_References_Name; ?>	<?php echo $nurse->Personal_References_Name; ?>
Personal References Address	Personal_References_Address; ?>	<?php echo $nurse->Personal_References_Address; ?>
Personal References Telephone	Personal_References_Telephone; ?>	<?php echo $nurse->Personal_References_Telephone; ?>
Profesonal References Name	Profesonal_References_Name; ?>	<?php echo $nurse->Profesonal_References_Name; ?>
Profesonal References Address	Profesonal_References_Address; ?>	<?php echo $nurse->Profesonal_References_Address; ?>
Profesonal References Telephone	Profesonal_References_Telephone; ?>	<?php echo $nurse->Profesonal_References_Telephone; ?>
Additional Certifications
Additional Certificate Details	View	<?php echo $documentsrem[_ADDL_CERTIFICATE_][$i]; ?>
Emergency Contact
Name	Emergency_Contact_Name; ?>	<?php echo $nurse->Emergency_Contact_Name; ?>
Relationship	Emergency_Contact_Relationship; ?>	<?php echo $nurse->Emergency_Contact_Relationship; ?>
Address	Emergency_Contact_Address); echo $x->Emergency_Contact_Address.','. $x->Emergency_Contact_zipcode; ?>	<?php echo $nurse->Emergency_Contact_Address; ?>
Telephone	Emergency_Contact_Telephone; ?>	<?php echo $nurse->Emergency_Contact_Telephone; ?>
Cellphone	Emergency_Contact_Cellphone; ?>	<?php echo $nurse->Emergency_Contact_Cellphone; ?>
Other	Emergency_Contact_Other; ?>	<?php echo $nurse->Emergency_Contact_Other; ?>
Email	Emergency_Contact_Email; ?>	<?php echo $nurse->Emergency_Contact_Email; ?>
Lives with patient	live_with_patient; ?>	<?php echo $nurse->live_with_patient; ?>
Have Keys or access to home	have_key; ?>	<?php echo $nurse->have_key; ?>
Caregiver Preference
Preffered Gender	Preffered_Gender; ?>	<?php echo $nurse->Preffered_Gender; ?>
Notes	Notes; ?>	<?php echo $nurse->Notes; ?>
Accept		YES NO
Rejection Note