Occupational Health Department CHILD CARE WORKER Program Elements FY12 YES NO COMMENTS/% Compliance Is documentation of required 1 immunizations MMR/Polio and Varicella 2 Has Hepatitis A series been offered *Declination form mandatory 3 If Hepatitis A given, was series completed Were Hepatitis A surface Antibodies 4 obtained after series completed 5 Td/Tdap current 6 Annual PPD current 7 Is PC Matrix in medical record 8 Has Flu vaccine been offered Records Screened for compliance Date Last name Last 1 2 3 4 5 6 7 8 4SSN __________________________________ _____________ Validated by/Program Manager Signature Date
Occupational Health Department CHILD CARE WORKER Program Elements FY12 YES NO COMMENTS/% Compliance 1 Is documentation of required immunizations MMR/Polio and Varicella 2 Has Hepatitis A series been offered *Declination form mandatory 3 If Hepatitis A given, was series completed 4 Were Hepatitis A surface Antibodies obtained after series completed 5 Td/Tdap current 6 Annual PPD current 7 Is PC Matrix in medical record 8 Has Flu vaccine been offered Records Screened for compliance Date Last name Last 4SSN 1 2 3 4 5 6 7 8 __________________________________ _____________ Validated by/Program Manager Signature Date
Childcare-Worker.docx