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Vaccination Status Self-Declaration Form

The document is a Self-Declaration form for candidates to report their vaccination and immunization status during a Pre-Employment Medical Examination. It includes sections for Hepatitis B and Varicella Zoster (Chickenpox) vaccination details, as well as a declaration of the accuracy of the provided information. Candidates must also submit evidence of vaccination or test results as required.

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Nasreen Sheikh
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317 views1 page

Vaccination Status Self-Declaration Form

The document is a Self-Declaration form for candidates to report their vaccination and immunization status during a Pre-Employment Medical Examination. It includes sections for Hepatitis B and Varicella Zoster (Chickenpox) vaccination details, as well as a declaration of the accuracy of the provided information. Candidates must also submit evidence of vaccination or test results as required.

Uploaded by

Nasreen Sheikh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Self-Declaration for Vaccination / Immunization Status

(To be filled in by the Candidate at the time of Pre- Employment Medical


Examination)
Name: ________________________________________ Position applied for:__________________

Department: _________________________

Date of Pre-Employment Medical Examination: ____________________

Phone No: ________________________ Date____/____/________

Immune Status for Hepatitis B


 3 doses of Hepatitis B vaccine Taken Vaccine. * Yes / No
(0, 1 month and 6 month)
 Vaccination Date 1st Dose _____________, 2nd Dose _____________, 3rd Dose _______________

 Anti HBs Ab test done* Yes / No Result _____________________


Date ______________________

Immune Status for Varicella Zoster (Chickenpox)


 History of Chicken pox earlier (Age less than 14 yrs) Yes / No

 2 dose of VZV/Chickenpox vaccine taken * Yes / No


Vaccination Date 1st Dose _____________, 2nd Dose _____________,

 VZV IgG Antibody test done* Yes / No Result _____________________


Date ______________________

Declaration: I hereby declare that all the information provided in this questionnaire is correct and true and I
acknowledge complete responsibility for such, whether written in by me or by another person on my behalf.

Full Name________________________________ Signature__________________________________

*For each disease requiring evidence of vaccination provide at least ONE of the following:
1. Documentation on Vaccination Card or immunization card equivalent
2. Included in a statement from a GP Practitioner on the Practitioner letter head.
3. Kindly provide laboratory test report for Anti HBs Ab &/ VZV IgG Antibody.

Office use only


Immunization Declaration Form completed and required evidence received: Yes / No

Doctor’s Name: _______________________

Sign ________________ Date _______________

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