OTHER VACCINES Site / Route Provider Vaccine Date Given Dosage Manufacturer Lot Number LA RA LL Initials ZOSTAVAX) RL Zoster (ZVL SQ mL Zoster (RZV SHINGRIX) IM mL (RZV Zoster SHINGRIX) IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL TUBERCULOSIS (TB) TESTING Test Types: Blood Assay for M. tuberculosis (BAMT) or Tuberculin Skin Test (TST) Results Pos or Neg Test Type Reading (BAMT or TST) Provider Provider Testing Lot Number Date, (for TST, record Date and Initials Initials for TST mm of induration) ADDITIONAL TB INFORMATION FOR PUBLIC HEALTH* Date of positive BAMT or TST: MM induration (TST): Diagnosis: Latent TB Infection TB Disease Treating physician: Medications and Regimen_ Treatment start date: Treatment completion date: Drug resistance: Date of last chest X-ray: Results: *This section must be completed if the patient’s folder is archived or destroyed CH-2A (Rev 3-27-18)
OTHER VACCINES Vaccine Date Given Site / Route LA RA LL RL Dosage Manufacturer Lot Number Provider Initials Zoster (ZVL ZOSTAVAX) SQ mL Zoster (RZV SHINGRIX) IM mL Zoster (RZV SHINGRIX) IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL SQ IM mL TUBERCULOSIS (TB) TESTING Test Types: Blood Assay for M. tuberculosis (BAMT) or Tuberculin Skin Test (TST) Testing Date Test Type (BAMT or TST) and Lot Number Provider Initials Reading Date, for TST Results Pos or Neg (for TST, record mm of induration) Provider Initials ADDITIONAL TB INFORMATION FOR PUBLIC HEALTH* Date of positive BAMT or TST: MM induration (TST): Diagnosis: Latent TB Infection TB Disease Treating physician: Medications and Regimen_ Treatment start date: Treatment completion date: Drug resistance: Date of last chest X-ray: Results: *This section must be completed if the patient’s folder is archived or destroyed CH-2A (Rev 3-27-18)
CH2AVaccineAdministrationRecordandTBTesting%20Rev%203-27-18%20-%20Final.docx