HEALTH REQUIREMENTS FORM - promedicaorg 2026

1. Click ‘Get Form’ to open the HEALTH REQUIREMENTS FORM in the editor.
2. Begin by entering your personal information in the 'TO BE COMPLETED BY LEARNER' section. Fill in your name, email, phone number, and emergency contact details.
3. Indicate your sponsoring institution and program of study. This helps ProMedica understand your educational background.
4. Provide documented proof of liability coverage and current CPR certification, including expiration dates where applicable.
5. Complete the REQUIRED PROOF OF IMMUNITY section by listing vaccination dates for Rubella, Rubeola, Mumps, Varicella, and Hepatitis B. If you decline any vaccinations, ensure to initial accordingly.
6. Fill out the ANNUAL INFLUENZA VACCINE section with the date of your most recent vaccine or indicate if you have a valid reason for declining.
7. Document TB test results in the REQUIRED TB DOCUMENTATION section. Include both dates and results for the 2-Step PPD test or T-Spot/Quantiferon.
8. In the FITNESS FOR DUTY section, ensure that a licensed health professional attests to your fitness for duty by providing their printed name, title, signature, and date.
9. Finally, submit the completed form to your ProMedica affiliation coordinator as per processing instructions.

Start filling out your HEALTH REQUIREMENTS FORM today using our platform for free!