Chapter 5 – Clinical Staffing of the Health Resources and Services Administration (HRSA) Health Center Program Compliance Manual (Chapter 5: Clinical Staffing  – Health Center Compliance Manual) requires health centers to verify immunization and communicable disease status for all clinical staff providing clinical services upon initial hire and at the time of reappointment.  In accordance with the HRSA Health Center Program Site Visit Protocol:  Examples of Credentialing and Privileging Documentation (Examples of Credentialing and Privileging Documentation – Health Center Site Visit Protocol), it is at the discretion of the health center to determine what vaccinations are required for all clinical staff, based on state and other requirements.  Additionally, it is at the discretion of the health center to determine communicable disease screening protocols for all clinical staff, as well as what sources of verification will be accepted and in what circumstances clinical staff members have the option to decline.

Below are some tips for ensuring compliance with the requirements for verification of immunization and communicable disease status:

• Develop and implement a policy that outlines the immunization and communicable disease status requirements for all clinical staff. Typically, the requirements upon initial hire are more comprehensive than what is required annually and upon reappointment.
• When developing, reviewing, or revising the Credentialing and Privileging Policy, redirect the reader to the health center’s policy for immunization and communicable disease status requirements.
• Manage exemptions consistently by outlining the grounds for exemptions (medical, religious, etc.), as well as the documentation required to support exemption requests.
• Ensure paper meets practice and validate implementation of the process.
• Conduct audits on a routine basis to ensure records for immunization and communicable disease status are complete, accurate and up to date.