ATTACHMENT F

Documentation of Student/Employee Hepatitis B Vaccination Status

Documentation of Student/Employee

Hepatitis B Vaccination Status

(To be maintained by the providing medical facility.)

Please check all that apply:

1.   Hepatitis B Vaccination Series received  ______________________________

a.     Date and Location of Administration of the Vaccine/Booster:

(1)  ____________________  __________________________________________

(2)  ____________________  __________________________________________

(3)  ____________________  __________________________________________

(4)  ____________________  __________________________________________

(5)  ____________________  __________________________________________

(6)  ____________________  __________________________________________

 

2.   Antibody Testing indicates employee/student is immune to Hepatitis B  ___________

A.     Date and Location of Testing

(1)  ____________________  __________________________________________

(2)  ____________________  __________________________________________

(3)  ____________________  __________________________________________

(4)  ____________________  __________________________________________

(5)  ____________________  __________________________________________

(6)  ____________________  __________________________________________

 

3.      Hepatitis B vaccine is contraindicated for medical reasons  _____________________

4.   Employee/student declines the vaccination series (attach signed statement)  ________

__________________________________________        __________________________

Signature of Official from University Medical Center              Date