CONFIDENTIAL RECORD
_____________________________________________ _________________________
Employee Name (last, first, middle) Social Security No.
Job Title: _____________________________________________________________________
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Hepatitis B Vaccination Date |
Lot Number |
Site |
Administered by |
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1. |
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2. |
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3. |
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Additional Hepatitis B status information: ___________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Post-exposure incident: (Date, time, circumstances, route under which exposure occurred)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Identification and documentation of source individual: _________________________________
Source blood testing consent:
_____________________________________________________________________________
Description of employee's duties as related to the exposure incident: ______________________
_____________________________________________________________________________
_____________________________________________________________________________
Copy of information provided to health care professional evaluating an employee after an exposure incident: ______________________________________________________________
______________________________________________________________________________
Attach a copy of all results of examinations, medical testing, follow-up procedures, and health care professional's written opinion.
Training Record: (Date, time, instructor, location of training summary)
______________________________________________________________________________
______________________________________________________________________________
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Approved: 6/12/89 |
Reviewed: 10/14/19 |
Revised: 2/9/09; 4/8/13 |