Attachment_3_Sample_Imm_Form.docx
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- W91YTZ-16-R-0058
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Department of the Army Medical Command
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Attachment 3 Sample Immunization Form
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ATTACHMENT 3 IMMUNIZATION FORM
EMPLOYEE'S NAME_____________________________________________________________________
HEPATITIS B
Serologic Testing Hepatitis Vaccine: (Specify Dates and Results):(Specify Dates Doses Given):
HbsAG _________________________ Dose #1 _______________ Dose #2 ______________
HbsAB _________________________Dose #3 _______________ Booster _______________
TB STATUS
Mantoux Test PPD Chest X-ray
| PPD Given: _____________________ | Date of CXR: _____________________ | |
| PPD Read: _____________________ | CXR Results: _____________________ | |
| Results: _____________________ | Results of Evaluation and Indication for Treatment: ______________________________________________________________________________________ |
MEASLES/MUMPS/RUBELLA
Positive Antibody Titer MMR Immunization (Specify Dates and Results): (Specify Dates Doses Given):
Measles: ______________________________ Dose #1 ________________________________ Mumps: _____________________________ Dose #2 ________________________________ Rubella: _____________________________
TETANUS / DIPHTHERIA/ PERTUSSIS
(Specify Dates Given)
Date Primary Series Completed: _________________ Date Given: ________________(Most Recent Booster)
VARICELLA
___ Documented History of Illness by Physician
Positive Antibody Titer (Specify Dates and Values): __________________________________________ Varicella Immunization Given: __________________________________________________________
CURRENT INFLUENZA VACCINATION
Medically Contraindicated ______ Local Supply Depleted______ Date Given:________Injectable____Intranasal_____
Print Name of Verifying Provider: ___________________________________________________________ Telephone: ________________________________________________________________________________ Address: _________________________________________________________________________________ SIGNATURE & DATE: _______________________________________________________________________ Email: ________________________________________________________________________________________
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