ExhibitDImmunization_Status_Format.docx

Occupational Physical Examination Certificate

NAME: DATE:

Physical/Immunization Requirements: (Please see attached immunization requirements)

Please provide the dates of the following:

TEST DATE RESULTS

· Tetanus N/A

· Hepatitis B Titer (lab results copy needed) _____________ _____________

· If no immunity to HepB, Please provide all three dates of Series (lab results copy needed):

1. ____________________

2. ____________________

3. ____________________

· Annual Influenza (Fall) N/A

· PPD Tuberculin Skin Test (copy needed)

· Occupational Physical Examination _____________ _____________

CONFIRMATION OF THE APPLICANT’S DECLARATION

I have been given written proof of the above vaccinations/tests. I have examined the above named individual and to the best of my knowledge is free of all contagious diseases and has no evidence of any acute or chronic physical or mental problems that might interfere with the individual’s ability to perform his/her duties.

Physician’s Certification (Signature/Stamp Required) Date of Certification Print name of physician

**NOTE:

· Form cannot be filled out by the MEPS CMO

· You must attach all supporting documentation which includes any documented medical or religious reason for not taking a particular test.

Revised 10/22/14