Required Immunizations Form (Page 2 of 3) in pdf

Required Immunizations Form Page 2

EMPLOYEE HEALTH & WELL-BEING

2450 Holcombe Blvd, Unit 631 Houston, TX 77021

Office: (713) 745 – 6900 Fax: (713) 745 - 7164

LAST NAME

FIRST NAME

DATE OF BIRTH

DEPARTMENT

DATE _________________________________________

REQUIRED IMMUNIZATIONS

(Please provide month, day and year)

1. Varicella

Positive history of chicken pox disease or

____________________________________

Varicella vaccine series (2 injections given after 1995) or #1

Serologic confirmation by varicella titer (attach positive lab report)

______

2. Tuberculin skin test (PPD) (required within the last 12 months, unless documentation of a past positive PPD (over 10

mm induration.) * A TB skin test is required, even if you have received BCG vaccination, unless documentation of a 10 mm

positive reaction is provided.

Date:

Result:

negative (mm)

positive (measurement in

mm)

If positive, did you take isoniazid (INH) prophylaxis?

Yes

Chest x-ray findings if PPD is positive, completed after positive skin test (attach x-ray report)

Date of chest x-ray:

Result:

( ) No evidence of active tuberculosis

( ) X-ray consistent with active tuberculosis

( ) Abnormal x-ray, but not due to tuberculosis

Health Care Provider Signature

Please print name

* Signature confirms immunization record transcription or administration.

Address

City

State

Zip Code

Phone Number

Fax Number

Required Immunizations Form Page 2