Consent Form Hiv Test Page 19
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42IMMUNIZATIONS
TYPE
DATE
INIT.
DATE
INIT.
DATE
INIT.
DATE
INIT.
DATE
INIT.
DATE
INIT.
Diphtheria/Tetanus
Tetanus - Toxoid
PPD (5TU) Results
(Induration in mm)
Influenza Vaccine
Pneumovac Vaccine
Polio
Other (Specify)
_______________
COMMUNICABLE DISEASES (Enter Date Tested Positive/Treated and Initials))
Meningococcal
Date Tested Positive:
Date Treated:
Hepatitis A
Date Tested Positive:
Date Treated:
Hepatitis B
Date Tested Positive:
Date Treated:
Syphilis
Date Tested Positive:
Date Treated:
Tuberculosis
Prevention
Date Tested Positive:
Date Treated:
Tuberculosis
Active Treatment
Date Tested Positive:
Date Treated:
H.I.V.
Date Tested Positive:
Date Treated:
Other (Specify)
_______________
Date Tested Positive:
Date Treated:
SIGNATURE & TITLE
INIT.
SIGNATURE & TITLE
INIT.
Immunization/Treatment to be
INSTRUCTIONS:
ADDRESSOGRAPH:
administered, and form completed by a Licensed Nurse. See
FSHOP 150-58, “Immunization and Preventive/Active
Treatment of Certain Communicable Diseases” and FSHOP
155-2, “Human Sexuality.”
Form to be brought forward with each admission.
Form to be filed in Flow Sheet section of the ward chart.
*** CONFIDENTIAL & PRIVILEGED INFORMATION *** FOR PROFESSIONAL USE ONLY ***
FLORIDA STATE HOSPITAL, CHATTAHOOCHEE, FL 32324
IMMUNIZATION/TREATMENT RECORD
Form 13, (Revised) Mar 01
FLORIDA STATE HOSPITAL
COMMUNICABLE DISEASES/
Office of Primary Responsibility: Health Care Services Medical Service Director
Attachment 4
EDUCATION FORM
Page 1 of 2
Page 1 of 2
Operating Procedure 153-31
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