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)(b) 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
100 Easton Drive, Selkirk, MB
204-785-4717 | 204-785-4753 | [email protected]
Before You Start
As part of the onboarding and intake process, you will be asked to provide any available documentation that supports your current immunity (e.g. vaccines, immunity testing records) and tuberculosis (TB) testing status.
Later in this form, you will have the option to consent to Occupational Health accessing your immunization and TB testing records from Manitoba’s provincial health databases, including PHIMS and Cadham Provincial Laboratory. If you provide consent, you do not need to upload records for vaccines or serology testing completed in Manitoba. However, you are encouraged to upload any records from outside Manitoba, post-secondary programs, or past employers, as these may not be available through provincial systems.
Helpful Resources
- Manitoba Health – Immunization Record (PHIMS)
To request a copy of your immunization record from Manitoba’s provincial immunization registry (PHIMS):
https://forms.gov.mb.ca/immunization-update-request/ - Red River College Polytechnic – Release of Health Records
For individuals whose immunizations or TB screening were completed through RRC:
https://hub.rrc.ca/Forms/Start/ConsentHealthInfo - University of Manitoba – Rady Faculty of Health Sciences
Former students or trainees of the College of Nursing, Medicine, or other health programs can request archived records:
https://umanitoba.ca/health-sciences/immunization-program
Submission Instructions
If you are submitting your own immunization or lab records, you may do so by:
- Uploading through the Occupational Health Intake Form
- Fax: 204-785-4753
- In person or via interdepartmental mail (IDM) to:
Occupational Health Nurse
Interlake-Eastern RHA
100 Easton Drive
Selkirk, Manitoba
R1A 1C9
Important: Please include your full name and date of birth on all documents.