Exhibit F - Immunization Form.pdf
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- Solicitation number
- HT001524R0030
- Issued by
-
Defense Health Agency
About this file
This document is an immunization form for contract employees working at the AT Augusta Military Medical Center Ambulatory Care Center. The form requires documentation of immunizations for measles, mumps, rubella, varicella, tetanus, diphtheria, pertussis, tuberculosis, hepatitis B, and seasonal influenza. For tuberculosis, two tuberculin skin tests within the past 12 months are required, and a chest x-ray is needed if the PPD test is positive. The contract opportunity is solicitation number HT001524R0030 from the Defense Health Agency to provide services at the AT Augusta Military Medical Center Ambulatory Care Center. Contractors must ensure their employees meet all immunization requirements on the form.
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Text version
EXHIBIT F - IMMUNIZATION FORM
EMPLOYEE'S NAME:
MEASLES/MUMPS/RUBELLA MMR Immunization (specify dates doses given)
Date of Measles titer _____/_____/_____ 1st vaccination _____/_____/_____
Date of Mumps titer _____/_____/______ 2nd vaccination _____/_____/_____
Date of Rubella titer _____/_____/______
VARICELLA TITER REQUIRED VARICELLA VACCINATIONS
Date of Varicella titer _____/_____/_____ Immune Not immune 1st vaccination _____/_____/_____
Verbal History of illness: (circle) YES NO 2nd vaccination _____/_____/_____
Tetanus diphtheria (Td) Tetanus diphtheria accellular pertussis (Tdap) Date of last booster dose _____/_____/_____ Date of vaccine _____/_____/_____
TUBERCULOSIS: 2 TUBERCULIN SKIN TESTS WITHIN PAST 12 MONTHS REQUIRED
Type PPD 1st _____/_____/_____ PPD 2nd _____/_____/_____ Result (circle) Positive (mm) Negative Positive (mm) Negative
If positive PPD, Chest x-ray must be within 12 months.
Chest x-ray date _____/_____/_____
Results (circle) Negative Positive Results ________________________________
BCG History: (circle) YES NO
HEPATITIS B VACCINATIONS
Serologic Teasing (Specify dates and results) Hepatitis Vaccine (Specify dates doses given)
HbsAG _____/_____/_____ Dose#1 _____/_____/_____ Dose#2_____/_____/_____
HbsAB_____/_____/_____ Dose#3 _____/_____/_____Booster _____/_____/_____
Seasonal Influenza Vaccination Date of Vaccination: ________________________
(To be completed by Occupational Health Fort Belvoir Community Hospital)
CONTRACT EMPLOYEE HEALTH IMMUNIZATION REVIEW:
The contract employee meets all immunization requirements:
Yes_____ No _____
Outstanding requirements:
Reviewed by: ___________________________________ Date: ___________________________
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