Occupational Health Department ANIMAL ASSOC. DISEASE Program Elements FY12 YES NO Comments/%Compliance Is the physical exam completed at correct 1 periodicity 2 Is OPNAV 5100/15 current Is the PC Matrix # 207 in the medical record 3 (MR) and complete Are stressor-specific and special 4 examinations provided per written requirements Are immunizations current: documented 5 Titers, Td, TB Screening and Rabies vaccine per identified Risk Category Are correct procedures ordered for 6 examination as required in PC Matrix Records screened for compliance Date Last Name Last 1 2 3 4 5 6 Comments 4SSN __________________________________ _____________ Validated by/Program Manager Signature Date
Occupational Health Department ANIMAL ASSOC. DISEASE Program Elements FY12 YES NO Comments/%Compliance 1 Is the physical exam completed at correct periodicity 2 Is OPNAV 5100/15 current 3 Is the PC Matrix # 207 in the medical record (MR) and complete 4 Are stressor-specific and special examinations provided per written requirements 5 Are immunizations current: documented Titers, Td, TB Screening and Rabies vaccine per identified Risk Category 6 Are correct procedures ordered for examination as required in PC Matrix Records screened for compliance Date Last Name Last 4SSN 1 2 3 4 5 6 Comments __________________________________ _____________ Validated by/Program Manager Signature Date