Form N: Employee Medical Record

EMPLOYEE MEDICAL RECORD FORM OF VACCINATION AND EXPOSURE INCIDENTS

Employee Name

Employee Address

Employee Social Security Number

Employee starting date

Employee termination date (if any) ___________

History of HBV vaccination (date received or, if not received, a brief explanation of

why not)








Results of medical follow-up procedures regarding exposure incidents

Date Name of Physician Seen Written Report Received from Physician

*Release of information required before sending to physician

Note: Maintain this record for the duration of employment plus 30 years.