Intredersscreening Rijnstate - observership | Vaccinatiecentrum TravelClinicOost -

Name*

Initials Last name

Private e-mailadress*

Gender*

Male
Female
Non binary

Date of birth*

YYYY

Country of birth*

Telephone number*

Department you are going to work*

Profession*

Start date*

YYYY

MRSA

When you arrive in the Netherlands you need to be tested as soon as possible. You will receive an e-mail with information on how to get the test. Do you agree?*

Yes
No

Hepatitis A

Are you going to work at one of the following departments: endoscopy or general technology?*

Yes
No

Are you vaccinated against hepatitis A?*

Yes
No

If yes: Please upload your vaccination pasport below*

Max. bestandsgrootte: 64 MB.

Did you have hepatitis A?*

Yes
No

Please upload the test results below

Max. bestandsgrootte: 64 MB.

TCO will contact you via e-mail

Hepatitis B

Did you receive a series of three vaccinations against hepatitis B?*

Yes
No

Do you have an official document regarding the results of the anti-HBs titer?*

Yes
No

Please upload the vaccination pasport and/or the negative result on HBsAG and negative anti-HBc, not older than three months on the moment you start at Rijnstate

Upload the proof*

Max. bestandsgrootte: 64 MB.

Upload you vaccinationpasport*

Max. bestandsgrootte: 64 MB.

Did you receive one or two vaccinations against hepatitis B?*

Yes
No

Upload your vaccinationpasport*

Max. bestandsgrootte: 64 MB.

Do you have chronic hepatitis B?*

Yes
No

TCO will contact you via e-mail

MMR (mumps, measles, rubella)

Did you receive the vaccinations against measles, mumps and rubella?*

Yes I received the MMR 1 time
Yes I received the MMR 2 times
No I am not vaccinated

TCO will contact you via e-mail

Did you have the measles as a child?*

Yes
No

TCO will contact you via e-mail

Chicken-pox and whooping cough

Are you going to work at one of the following departments: children’s department, neonatology, obstetrics, midwifery or gynecology?*

Yes
No

Did you have the chicken-pox?*

Yes
No

TCO will contact you via e-mail

Were you vaccinated against whooping cough within the last five years?*

Yes
No

TCO will contact you via e-mail

What's the vaccination date?*

Tuberculosis

Did you live or work in the past 2 years in in the region of Africa , Asia, Central-East Europe, Central-South America?*

Yes
No

In which country did you live and/or work in the past two years?*

When did you leave for the country(ies) in question?*

When did you come back?*

While you were there, have you worked in a hospital, orphanage, homeless shelter, drug addicts, patients with hiv and/or refugees?*

Yes
No

Did you have tuberculosis in the past?*

Yes
No

Which treatment did you receive?

Are you vaccinated against tuberculosis?*

Yes
No

TCO will contact you via e-mail

Did you have a positive Mantoux-test in the past?*

Yes
No

TCO will contact you via e-mail

Did you take a TBC-test in the last six months?*

Yes
No

TCO will contact you via e-mail

Upload proof*

Max. bestandsgrootte: 64 MB.

Do you have symptoms related to tuberculosis at the moment (coughing, night sweats, fatigue, loss of appetite for the last three weeks?*

Yes
No

TCO will contact you via e-mail

Thanks for completing! You can add any additions below:*

If the completed screening form shows that action is required, you will be notified by email within two working days. If you receive an email from TCO, take action as quickly as possible to avoid delays in your commencement of employment. TCO will inform Rijnstate if you have been approved to start in your position. No medical data is shared. If you do not receive a message from TCO, this means that you have been approved to start. For questions about the screening form, please email tcoscreening@rijnstate.nl

Intredersscreening Rijnstate – observerships

MRSA

Hepatitis A

Hepatitis B

MMR (mumps, measles, rubella)

Chicken-pox and whooping cough

Tuberculosis

Intredersscreening Rijnstate – observership