Voluntary Self-Identification of Immunodeficiency

Why are you being asked to complete this form?

Due to the rising concerns around COVID-19 we want to take every precaution available for the health and safety of our staff and their family members (living within your household).  Should we be notified of an outbreak, we want to be able to notify you immediately so you and your family members, who may not be able to fight the virus, can begin self-isolation practices.

How do I know if I have an immunodeficiency?

You have an immunodeficiency if your body can’t defend itself against bacteria, viruses, or parasites.  You can have a secondary immunodeficiency disorder if you are undergoing anything that could weaken your immune system.  You or your family member will most likely have a diagnosis from a doctor of your immunodeficiency.

Immunodeficiency and secondary immunodeficiency disorders (and their causes) include, but are not limited to:

Immunodeficiency disorders:

  • X-linked agammaglobulinema
  • Common variable immunodeficiency
  • Severe combined immunodeficiency

Secondary disorders:

  • HIV/AIDS
  • Leukemia
  • Viral Hepatitis
  • Multiple Myeloma

Causes/Types

  • Severe burns
  • Chemotherapy
  • Radiation
  • Diabetes
  • Malnutrition
  • Respiratory Disorders
  • Heart Disease

 

 

Please check one of the boxes below
 

 

Disclaimer: This questionnaire is voluntary, you are not required to fill it out.  This information will be kept confidential in the Benefits Office and only used if necessary for the safety and protection of our employees and their immediate family members. Thank you.