404.3E4  HEPATITIS B VACCINE INFORMATION AND 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)

______________________________________________________________________

______________________________________________________________________