State Of Alaska Department Of Corrections - Employee Medical - Immunization And Ppd Record
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1STATE OF ALASKA
DEPARTMENT OF CORRECTIONS
Employee Medical – Immunization and PPD Record
(KEEP FOR 30 YEARS AFTER TERMINATION OR RETIREMENT)
Name
Last
First
M.I.
Birthdate:
/
/
DD
MM
YY
SS#:
Location:
Date of Hire:
Termination Date:
Rehire?
YES
NO
HEPATITIS B:
Date of Hepatitis B vaccine:
Date
Location
#1)
1.
#2)
2.
Prior vaccination date:
#3)
3.
Location:
TB: DATES AND RESULTS OF PPD:
Date
Results
Date
Results
Date
Results
1.
8.
15.
2.
9.
16.
3.
10.
17.
4.
11.
18.
5.
12.
19.
6.
13.
20.
7.
14.
21.
TB: Dates and results of screenings by private physician or PHN for persons with previous positive or documented TB.
Date
Results
Date
Results
Date
Results
1.
8.
15.
2.
9.
16.
3.
10.
17.
4.
11.
18.
5.
12.
19.
6.
13.
20.
7.
14.
21.
(If this individual has a positive skin test & screening, clearance must be obtained from a private physician or a Public Health Nurse)
Results of all PPD’s are all to be recorded in mm.
00 - 4mm
- negative
- repeat in 1 yr.
5mm - 9mm
- questionable
- repeat PPD in 3 weeks
10mm or greater
- positive
- refer to PMD or Public Health Nurse
Two-step testing will be does 1 week on persons who are over 40 and have had a PPD in the past 5 years. Questionable results
will be repeated in 3 weeks. Negative results will be repeated yearly.
Attach the following to this form:
1.
Copies of Workman’s Comp. Report
2.
Copies of all lab reports and exams Report
3.
Copy of informed consents/refusals
See back of page for additional comments.
Department of Corrections, Form 202.04A
Rev. 08/03
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