a151rr-resident-tuberculin-ppd-vaccine-record

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					                                          Senior Housing Management


                              EMPLOYEE TUBERCULIN PPD VACCINE RECORD


COMMUNITY:


I have read or have had explained to me the information on this form about PPD vaccine. I have had a chance to
ask questions which were answered to my satisfaction. I believe and understand the benefits and risks of PPD
vaccine and request that the vaccine be given to me or to the person named below for whom I am authorized
to make this request.

NAME: _____________________________________________                Birth Date: ________________________
ADDRESS: ___________________________________________________________________________________________
CITY: ______________________________             STATE: _____________ ZIP: __________________________
SIGNATURE OF VACCINATED PERSON OR PERSON AUTHORIZED TO MAKE THIS REQUEST:
_________________________________________________ DATE: _____________________

For Facility Use:
                                              STEP ONE
Vaccination Date:                 ____________________
Vaccination Result:               ____________________
Date Read:                        ____________________
Induration Diameter:              ____________________
Induration Height:                ____________________
Induration Color:                 ____________________
Vaccination Location:                               ______________
                                  ________________________________________
Vaccine Manufacturer: __________________________   Lot #: ___________ Exp. Date: __________
Chest X-ray Required?:            ________ yes      ________ no
Chest X-ray Result:               __________________________________________________________
Signature of Nurse Administering Vaccine: ________________________________ Date: _____________

                                        STEP TWO (if applicable)
Vaccination Date:                 ____________________
Vaccination Result:               ____________________
Date Read:                        ____________________
Induration Diameter:              ____________________
Induration Height:                ____________________
Induration Color:                 ____________________
Vaccination Location:                               ______________
                                  ________________________________________
Vaccine Manufacturer: __________________________   Lot #: ___________ Exp. Date: __________
Chest X-ray Required?:            ________ yes      ________ no
Chest X-ray Result:               __________________________________________________________
Signature of Nurse Administering Vaccine: ________________________________ Date: _____________

This form is to remain in a 3-ring binder in the Wellness Center until all tests are
completed.    Then it is to be filed in a separate file with SOP#P904 in the facility office.
                                              Senior Housing Management

                   EMPLOYEE HEPATITIS B VIRUS VACCINE RECORD


COMMUNITY:

I have read or have had explained to me the information on this form about Hepatitis B Virus
vaccine. I have had a chance to ask questions which were answered to my satisfaction.
I believe and understand the benefits and the risks of Hepatitis B Virus vaccine and request that
the vaccine be given to me or to the person named below for whom I am authorized
to make this request.


NAME: ______________________________________                                           Birth Date: __________________

ADDRESS: ________________________________________________________________________________

CITY: _________________________________                    STATE: ___________ ZIP: ____________________

SIGNATURE OF VACCINATED PERSON OR PERSON AUTHORIZED TO MAKE THIS REQUEST:

___________________________________________________                               DATE: _______________________

For office use only:

Hire Date: ____________________


1st Injection Date: ____________________
(To be given within 10 days of hire or date of request, if after hire.)

Signature of Nurse Administering Vaccine: ________________________________________

Date: ____________________


2nd Injection Date: ____________________                                  (To be given 30 days after first injection.)

Signature of Nurse Administering Vaccine: ________________________________________

Date: ____________________


3rd Injection Date: ____________________                                  (To be given 6 months after first injection.)

Signature of Nurse Administering Vaccine: ________________________________________

Date: ____________________

This form remains in a binder in the Wellness Center until the series is com-
pleted. Then it is filed in a separate file with SOP#P904 in the facility office.
                                       SENIOR HOUSING MANAGEMENT

                                RESIDENT TUBERCULIN PPD VACCINE RECORD


COMMUNITY:

I have read or have had explained to me the information on this form about PPD vaccine. I have had a chance to
ask questions which were answered to my satisfaction. I believe and understand the benefits and risks of PPD
vaccine and request that the vaccine be given to me or to the person named below for whom I am authorized
to make this request.

NAME: ________________________________________________ BIRTH DATE: ____________________________
ADDRESS: ___________________________________________________________________________________________
CITY: ________________________________________ STATE: ___________ ZIP: ________________
SIGNATURE OF VACCINATED PERSON OR PERSON AUTHORIZED TO MAKE THIS REQUEST:

___________________________________________________________ DATE: _____________________

For Facility Use:
                                               STEP ONE
Vaccination Date:                   ____________________
Vaccination Result:                 ____________________
Date Read:                          ____________________
Induration Diameter:                ____________________
Induration Height:                  ____________________
Induration Color:                   ____________________
Vaccination Location:                                   ______________
                                    ________________________________________
Vaccine Manufacturer: ___________________________Lot #: ___________Exp. Date: _________
Chest X-ray Required?:              ________ yes        ________ no
Chest X-ray Result:                 _______________________________________________
Signature of Nurse Administering Vaccine: ______________________________ Date: __________
                                              STEP TWO
Vaccination Date:                   ____________________
Vaccination Result:                 ____________________
Date Read:                          ____________________
Induration Diameter:                ____________________
Induration Height:                  ____________________
Induration Color:                   ____________________
Vaccination Location:                                   ______________
                                    ________________________________________
Vaccine Manufacturer: ___________________________Lot #: ___________Exp. Date: _________
Chest X-ray Required?:              ________ yes        ________ no
Chest X-ray Result:                 _______________________________________________
Signature of Nurse Administering Vaccine: ______________________________ Date: __________

This form is to remain in a 3-ring binder in the Wellness Center until all tests are
completed. Then it is filed in the resident's medical chart.

				
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