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EHSuppl_History_Form_Jun06

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					                   EMPLOYEE HEALTH OCCUPATIONAL HEALTH SUPPLEMENTAL HISTORY
NAME: .
DATE:
LAST 4 OF SS#:
VACCINES/IMMUNIZATIONS & SKIN TESTS ***PLEASE PROVIDE COPY OF DOCUMENTATION
OF IMMUNIZATIONS OR TITRES -- Have you had:
                                            YES   NO     UKN   Comment
Tetanus-Diphtheria
Polio
MMR (Measles,Mumps, Rubella)
Varicella (Chicken Pox)
Hepatitis B Vaccine
Others
TB Skin Test - If Yes, when?
TB Test Positive
TB Test Negative
Chest Xray - If Yes, when?
INH -- if yes, when?
CHILDHOOD DISEASES AND INFECTIOUS DISEASES -- Have you had:
                                         YES      NO      UKN                                                                        Comment
Measles
Mumps
Varicella (Chicken Pox)
Rubella (German Measles)
Hepatitis A, B, C
TB
ALLERGIES
Latex or rubber
Soaps or detergents
Animal saliva protien, dander, feathers, or fur
REPRODUCTIVE HISTORY                                                                     YES            NO             UKN           Comment
Have you had children or are you pregnant?
How many children?
Birth defects, stillborn, miscarrage?
EXERCISE                                                                                 YES            NO             UKN           Comment
Biking, Runing, Swimming, Weight Training etc.
PHYSICAL CAPABILITIES
Do you have any limitations? For example: lifting, pushing,
pulling, walking, standing, stair climbing, reaching above the
shoulder, repetitive motions, or bending. If yes indicate the weight
limit, duration or length of activity.
EXPOSURE HISTORY                                                                         YES            NO             UKN           Comment
Have you had an unprotected work exposure? If yes, what?
Do you have a history of a job related accident or disease? If yes,
what?
OSHA STATEMENT FOR HEPATITITS B VACCINE
If you have potential exposure to blood and/or body fluids, even one time a month, Hepatitis B vaccine is recommended. The vaccine is offered at no
expoense, in a series of three injections over six months. Please inform the Employee Health Program staff if you do not start the series today that you wish
the vaccine. I understand that due to my occupational exposure to blood or other potentially infectious material I may be at risk of acquiring Hepatitis B virus
(HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself. Howerver, I decline hepatitis B
vaccination at this time. I understand that by declining this vaccine, I contnue to be at risk of acquiring hepatitis B which is a serious disease. If in the future I
continue to have occupational exposure to blood or other potentially infectious materials and I want to be vacinated with hepatitis B vaccine, I can receive the
vaccinaation series at no charge to me. [Ref:CFR 1910.1030, Appendeix A.)

YES, I want the vaccine                                                                  NO, I do not want the vaccine
Signature:                                                                                Date:

     MS/06

				
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posted:11/6/2011
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