Employee Health Services / Forms

Medical Clearance Forms

LAUSD Form 8457 4_2023 - Certificate of Medical Examination

OCMD_Certificate of Medical Examination Form_8457_4_2023.pdf 240.38 KB (Last Modified on May 16, 2023)

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Tuberculosis Compliance Forms

Form 8478 TB Certificate of Completion

TB Risk Assessment Questionnaire (for information only)

Tuberculosis_Compliance_Forms_rev 11.2022 logos.pdf 421.9 KB (Last Modified on November 29, 2022)

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TB Results Form for Current Employees

Form 8472 TB Results for Current Employees only

8472_TB Test Results_04.2017.pdf 35.60 KB (Last Modified on April 18, 2017)

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Annual Declination of Influenza Vaccine

HR Form 8425

8425_Annual Declination of Influenza Vaccine_7.2017.pdf 36.83 KB (Last Modified on August 16, 2017)

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SB 792 Immunization Clearance Form

HR Form 8426

All employees working with preschool-aged children (Early Education Centers and/or Early Childhood Special Education classrooms) must complete this form.

8426_SB792 Immunization Clearance Form_7.2017.pdf 24.58 KB (Last Modified on July 27, 2017)

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