South.East Regiernal Health Author:irv
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Sr:d-Est
EMPLOYEE IMMUNIZATION FORM The immunization of employees ,b an essential part of the SERHA's Employee Health and lnfection Control
Programs. Immunizations are part of the employment package offered to all emptoyees fo ensure employees, his/her co-workers and patients are protected from these transmittable diseases.
EMPLOYEE NAME
1.
DATE OF BIRTH
Tetanus and Diphtheria last dose Td adsorbed
OR *Tdap (Tetanus, Diphtheria &
*
2.
Pertussis)
Date
Lot No
Date
Lot No
One dose of Acellular Peftussis is recommended. fTrade names: Boostrix, Adacel] (Employee Health Seryrbes will administer if required)
MeasleslMumpslRubella Assessment
Vaccine L Date (if born after 1970) 2. Date
Two doses of MMR
Lot No Lot No
H
MEASLES
MUMPS
nla
nla
Serologv (date and results)
RUBELLA (required if born before 1970 not applicable if had 2 doses of MMR)
Titre:
Historv of Disease 3.
varicella
Disease
History of Positive lf neqative or unknown Serology lmmunization if indicated:
!
Negative
results
1 Dose # 2 Dose #
I
Unknown
Date
Date
Lot No
Date
Lot No
4. Hepatitis B (if applicabte) Dates of
n
lmmunizaton
Booster
1.
1.
2.
2.
3.
3.
Serology results: Date: 5. Tuberculosis: A 2-step Mantoux test is required or chest x-ray if employee has previously tested positive. Date 1't step planted Results Date Date 2nd step planted BCG
previously
lf unable to have 6.
Results
yes
n
n
Date
positive yes n Mantoux: chest X-ray (within past year) Results No
Known
lnfluenza: Annual influenza immunization is highly recommended. Last lmmunizations reviewed and/or updated (H
ealthcare P rovi der
Physician Signature
fI
Date
Flu Vaccine Date
natu re
Date
Date Page2of
NOTE:
S ig
No
2
Form # 401 - 05/09 reptaces 10/08 This is a CONTROLLED document. Any document appearing in paper form is not controlled and should ALWAyS be printed on 1llt2O13 checked against the electronic version prior to
use.