Download Immunization and Screening Record

OCCUPATIONAL HEALTH IMMUNIZATION AND SCREENING RECORD
PLEASE PRINT:
NAME: ____________________________________________ DOB: ____________________ SS#: XXX-XX-_____________
DEPT: ____________________________________________ POSITION:_________________________________________
CONTRACT AGENCY NAME (If applicable) __________________________________________________________________
PLEASE STOP HERE. THE OCCUPATIONAL HEALTH NURSE WILL COMPLETE THE REST OF THIS FORM.
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DATE
SCREENING/IMMUNIZATIONS
RESULTS
INITIALS
Urine Drug Screen
PPD – Step I
PPD – Step II
Chest X-Ray
TB Questionnaire
Hepatitis B Titer
Mumps Titer
Rubella Titer
Rubeola Titer
Varicella – Titer
Respiratory Fit Testing – N95
Sm ______
Color Blind Test
Pass ______
Reg ______
PAPR______
Fail ______
VACCINATION ADMINISTRATION
Hepatitis B
MMR
Varicella
TD/TDAP
Influenza
Other
ADDITIONAL TITER INFORMATION
DATE
RESULTS
INITIALS
Hepatitis B
Rubeola
Mumps
Rubella
Varicella
CLEARED BY OCCUPATIONAL HEALTH MANAGER: _________________________________________________
DATE HUMAN RESOURCES NOTIFIED: _________________________
CONTRACT AGENCY NOTIFIED IF APPLICABLE:______________________
TUBERCULOSIS SCREENING and RESPIRATORY FIT TESTING (CONTINUATION FORM)
Employee Name:__________________________________
Date of
Screening
***Reason
A, E, F, PE
Type
PPD, Form, CXR
DOB:______________________
Induration
***Reason – Annual, Exposure, Follow up exposure, Pre-Employment
Respiratory Test
Date
Size:
Size:
Testing (Cont’d).
Small
Regular
Pass: ______
Fail: ______
Pass: ______
Fail: ______
Pass:
Fail:
Pass:
Fail:
Pass:
Fail:
______
______
______
______
______
______
Pass: ______
Fail: ______
Pass:
Fail:
Pass:
Fail:
Pass:
Fail:
______
______
______
______
______
______
Pass: ______
Fail: ______
Pass:
Fail:
Pass:
Fail:
______
______
______
______
Neg.
PAPR
Result
Pos.
Asx.
Initials
Normal