Occupational Health Employee Intake

Welcome to the IERHA Occupational Health Program. As part of your employment with Interlake-Eastern RHA, we ask you to complete this form to support your ongoing health and safety in the workplace.

This form collects the information we need to:

Review your immunization and health history as it relates to your role
Recommend any testing, vaccines, or follow-up needed to reduce workplace risk
Coordinate safe accommodations or protective measures if applicable
Communicate relevant information with you and if needed your healthcare team or employer, in line with applicable privacy laws

The Occupational Health Program is here to help prevent the spread of communicable diseases, support worker wellness, and to provide care that meets provincial safety and immunization guidelines for healthcare workers.

Privacy – Collection Notice

Your personal information is collected under the authority of section 36(1) of The Freedom of Information and Protection of Privacy Act (FIPPA), and your personal health information is collected under section 13(1) of The Personal Health Information Act (PHIA).

The information collected on this form will be used by IERHA Occupational Health to:

To reduce the risk of contracting or transmitting communicable diseases in the workplace
To assess eligibility for occupationally indicated vaccines, testing, and post-exposure follow-up
To determine immunity status and risk to yourself or others in the event of an exposure
To support health system planning, workforce safety, and HR management
To fulfill IERHA’s obligations to protect and promote public health

By completing this form, you give IERHA Occupational Health permission to assess and manage your occupational health needs. If you have questions before you begin, contact Occupational Health:

Occupational Health Nurse
Interlake-Eastern RHA, Selkirk Corporate Office
233A Main Street, Selkirk, MB
204-785-4717 | 204-785-4753 | [email protected]

Occupational Health Employee Intake

"*" indicates required fields

Step 1 of 5

Personal Information

Name*

First Last

Maiden or past names

Phone number

Date of birth (dd-mm-yyyy)*

Country of birth

Province of birth

Mailing address

Street or Box # City Province Postal Code

Position

Work site

A: PROGRAM CONSENT

Program Consent*

1. I understand that IERHA maintains an Occupational Health Surveillance Program designed to identify, assess, and address potential health and safety risks associated with my position. This program may include recommending vaccinations or tests for communicable diseases, managing exposure follow-up, conducting applicable hearing assessments, determining necessary accommodations or work restrictions, and implementing any other measures required under occupational health (OH) protocols in accordance with the Manitoba Workplace Safety and Health Act and Regulations.

2. I acknowledge that IERHA Occupational Safety & Health (OSH) policies and guidelines may be updated in response to new legislation, public health developments, or emerging medical evidence. I agree to complete required training, undergo recommended immunizations and testing, participate in applicable hearing evaluations, and comply with any additional protective measures or follow-up procedures relevant to my role.

3. I consent to the collection, use, and retention of my Personal Health Information (PHI) by IERHA OH in accordance with The Personal Health Information Act (PHIA). My PHI will be used exclusively for OH purposes(e.g., risk assessments, immunization reviews, necessary follow-up). Records will be securely stored for up to thirty (30) years, and access is strictly limited to authorized OH personnel. My PHI will only be shared beyond OH staff when required as mandated by law.

4. I understand that OH may disclose my PHI to external healthcare providers, facilities, or agencies when it is necessary for treatment, follow-up, or if disclosure is required by law or public health guidelines. When sharing information with my employer (e.g., HR or my manager), only the minimum necessary information will be provided to determine work accommodations or restrictions. Beyond these specific instances, my PHI remains confidential under PHIA.

5. I authorize IERHA OH to access, collect and update my immunization and testing records from provincial health databases (e.g., PHIMS, eChart), primary care providers, public health authorities, and other relevant institutions. I further authorize Manitoba Public Health to release a summary of my immunization records to OH for verification. If I possess immunization or testing records not available through these systems (e.g., from out-of-province providers, private clinics, or post-secondary institutions), I will submit them directly to OH.

6. I understand that if I restrict or revoke access to these records, OH may be unable to verify my immunization or testing status, which could affect my eligibility for certain duties. I will address any concerns with OH prior to signing this consent.

7. I understand that IERHA may compile and use aggregated, de-identified employee health data for internal research, quality improvements, or program planning. Any such data will lack personal identifiers and cannot be traced back to me.

8. I understand that this consent is valid throughout my employment with IERHA. If I leave and later rejoin, I maybe required to re-sign this or a similar consent to ensure my records remain accurate. I further acknowledge that I may withdraw or modify my consent by providing written notice to OH; however, doing so might limit my ability to perform certain duties or comply with workplace policies. OH will discuss any potential implications with me before finalizing any changes.

I confirm I have read, understood, and voluntarily agree to the above terms.*

Occupational Health Employee Intake

Privacy – Collection Notice

Occupational Health Employee Intake

Personal Information

A: PROGRAM CONSENT

B: INFORMATION SHARING CONSENT

C: ELECTRONIC COMMUNICATION CONSENT

Acknowledgment & Signature