407.3E2 Hepatitis B Vaccine Confidential Record

CONFIDENTIAL RECORD

 

_____________________________________________               _________________________

Employee Name (last, first, middle)                                                Social Security No.

 

Job Title: _____________________________________________________________________

 

Hepatitis B Vaccination Date

Lot Number

 Site

 Administered by

1.

 

 

 

2.

 

 

 

3.

 

 

 

 

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