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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Non-Employee Health Screening
Policy Number: 9.21
Effective Date: 06/01/2017
Chapter: Human Resources
To ensure that persons not employed by UW Health entities spending time at a UW Health location as
part of a clinical training program, students whose school has an affiliation agreement with UW Health,
volunteer program, temporary agency staffing program, third party entity (i.e., consultants), or military
service personnel on active duty have been:
A. Properly screened for communicable diseases prior to reporting to UW Health as required by
Wisconsin Administrative Code Chapter HFS 124.07 and UW Health Administrative Policy
9.20, Prospective Employee Health Assessment.
II. POLICY ELEMENTS
A. Wisconsin Administrative Code § HFS 124.07 requires a tuberculin skin test (TST) and the
vaccination or confirmed immunity against rubella and with known results prior to the
assumption of duties by person who will have direct contact with patients. Persons not in
compliance for tuberculosis screening and rubella immune status documentation may be removed
from UW Health premises until documentation has been completed.
B. In addition, based on recommendations from the Centers for Disease Control and Prevention,
those interventions noted in Section III of this policy will also be required.
A. Tuberculosis Screening
1. A two-step TST is required for all non-employees. One TST is required within 12 weeks of
starting at UW Health and the second TST within the past 12 months of starting at UW
a. If the non-employee has a history of a positive TST, he/she must be able to provide
documentation that they have been -deemed non infectious.
b. Negative interferon-gamma release assay test (i.e. quanti-FERON gold) will not be
accepted in lieu of the two-step TST.
c. A positive interferon-gamma release assay tests will be accepted in lieu of the two-step
2. Required vaccines or other blood tests will be provided by EHS only after the non-employee's
department agrees to pay the cost of such vaccines or blood tests.
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1. All non-employees must fulfill one of the following requirements:
A. Documentation of two doses of live vaccine on or after the first birthday,
separated by at least four weeks.
B. Laboratory confirmation of immunity. “Equivocal” does not constitute immunity.
2. A record of immunization or serologic test results must be on file at the non-employee’s
onboarding department or within Employee Health Services (EHS) if contracted to do so.
C. Hepatitis B Immunization
1. Those persons who have potential exposure to patients' blood or other potentially infectious
body fluids in the course of their service must have documentation of having:
A. Completed the hepatitis B vaccine series, which consists of three documented
dates and a positive titer or
B. A signed declination waiver, refusing the immunization or titer proving
D. Influenza Immunization
1. During periods in which the influenza immunization is actively offered by EHS, acceptance
of immunization or signing a declination waiver is required.
1. It is the responsibility of the onboarding department to ensure their non-employees are free of
communicable diseases before beginning at UW Health.
2. Exposure of a non-employee to a communicable disease (e.g., tuberculosis, meningococcal
disease, pertussis, varicella zoster) should be reported to the Infection Control Department.
Refer to UW Health Clinical Policy 4.1.6, Communicable Disease Exposure Response.
Should an immediate evaluation by EHS or ED be necessary, fees for services rendered by
EHS or ED will be charged to the exposed person or the agency that employs that person.
3. If a non-employee sustains an exposure to patient’s blood or body fluids, the non-employee
must report the exposure to EHS. If EHS is closed, the non-employee should follow their
employer’s process for after-hours exposures. This may include reporting to the ED, which
the cost of this visit may or may not be paid for by EHS.
4. It is the expectation that managers instruct non-employees not to enter airborne isolation
1. Departments who onboard non-employees are expected to provide EHS, upon request, all
necessary test/screening results.
1. Hospital Administrative Policy 1.24-Visitors in the OR: Students, Observers, Media Access
2. UW Health Administrative Policy 9.20- Prospective Employee Health Assessment
3. UW Health Clinical Policy 4.1.6-Communicable Disease Exposure Response
4. Wisconsin Administrative Code, Chapter HFS 124.07
5. Centers for Disease Control and Prevention (CDC): MMWR: Immunization of Health-Care
Personnel, November 25, 2011 / 60(RR07); 1-45 7.
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Sr. Management Sponsor: VP, Human Resources
Author: Clinic Manager, Employee Health Services
Reviewer(s): Infection Control Committee
Approval committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Chief Administrative Officer
Previous revision: 07/22/2013
Next revision: 06/01/2020