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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.
