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Employee Immunization Log

This document is an employee immunization record from the Negros Oriental Provincial Hospital Infection Prevention and Control Committee. It records an individual's name, birthdate, contact information, weight, height, medical notes, and vaccination history. The individual is instructed to take a copy of the record when visiting healthcare professionals to have it completed. Information on recommended immunization schedules can be found on the CDC website.

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Vin Bitz
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575 views4 pages

Employee Immunization Log

This document is an employee immunization record from the Negros Oriental Provincial Hospital Infection Prevention and Control Committee. It records an individual's name, birthdate, contact information, weight, height, medical notes, and vaccination history. The individual is instructed to take a copy of the record when visiting healthcare professionals to have it completed. Information on recommended immunization schedules can be found on the CDC website.

Uploaded by

Vin Bitz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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NOPH Employee Immunization Record

NEGROS ORIENTAL PROVINCIAL HOSPITAL ADDRESS:


INFECTION PREVENTION AND CONTROL COMMITTEE
BIRTHDATE (mm/dd/yy) AGE SEX
[42]
LAST NAME FIRST NAME M.I. INSTRUCTIONS
MEDICAL NOTES (allergies, vaccine reactions, etc.) Record the Type (HepB) and the Date (m/d/yy) for each vaccination given. For combin
HepB), complete a row under each separate antigen in the combination. Take a copy o
with you when you visit a healthcare professional. Have them assist you in completing
about the vaccines and recommended immunization schedules, see the Center for Dis
website at http://www.cdc.gov/vaccines

Date Given Administered By Next Dose Date Given


Vaccine Type (m/d/yy) (clinic, doctor, etc) Date Vaccine Type (m/d/yy)

Hepatitis B Hepatitis A
(HepB, Hib-HepB, HepA- (HepA, HepA-HepB)
HepB, DTaP-HepB-IPV)

Diptheria, Tetanus, Meningococcal


Pertussis (MCV4, MPSV4)
(DTaP, DTP, DT, Td, Tdap, Human papillomavirus
DTaP-HepB-IPV, DTaP-IPV/Hib,
(HPV4, HPV2)
DTaP-IPV, DTaP/Hib)
Zoster (shingles)
boosters
Influenza (yearly)
(TIV, LAIV)

Haemophilus
influenzae type b
(Hib, Hib-HepB, DTaP-IPV/Hib,
DTaP/Hib)

Pneumococcal
(PCV7, PCV13, PPSV23)

Other
Polio
(IPV, OPV, DTaP-HepB-IPV,
DTaP-IPV/Hib, DTaP-IPV)

Rotavirus
(RV1, RV5, RV [unknown])
CONTACT NUMBER:

WEIGHT HEIGHT

Record the Type (HepB) and the Date (m/d/yy) for each vaccination given. For combination vaccines (like Hib-
HepB), complete a row under each separate antigen in the combination. Take a copy of your immunization record
with you when you visit a healthcare professional. Have them assist you in completing the form. For information
about the vaccines and recommended immunization schedules, see the Center for Disease Control and Prevention
website at http://www.cdc.gov/vaccines

Administered By Next Dose


(clinic, doctor, etc) Date
(RV1, RV5, RV [unknown])

Measles, Mumps, & [42]


Rubella (MMR, MMRV) VACCINE INFORMATION LEAFLET:
Varicella (chickenpox) CONSENT:
(VAR, MMRV) SCREENING CHECKLIST:

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