Essay of Work
VOLUNTEERS Immunization and Health History
Name
Last - First - MI
Employee Health Center 325 Ninth Avenue, Box 359855 Seattle, Washington 98104
Social Security Number or EID :
* REQUIRED *
Home address
Street - City - State - Zip Code
Date of birth
Month - Date - Year
Gender:
Home (
M
F
)
E-mail
Telephone Department
Comments :
)
Cell (
HMC VOLUNTEERS
Job Title VOLUNTEER
Box Number 359788
Date began Yes No
Will you have possible exposure to blood or body fluids in your volunteer position?
Please fill non-shaded areas below. Shaded areas are office use. See reverse side for defining criteria and requirements.
Communicable disease immunization history
Disease Hepatitis B Measles (Rubeola) Mumps Rubella (3-day measls) MMR
Tetanus / Td / Tdap
Have you had this disease?
WBR Vaccination dates
UTD
ROI Antibody testing
Date of titer To lab
Yes / No
Dose 1
Dose 2
Dose 3
Most recent
Result (Pos / Neg)
Office use only
Varicella (chickenpox) Other: Other:
Tuberculosis screening
BCG vaccinated? Yes No Unknown Today's date: Last TB skin test Date Result TB skin test If positive TB test, did you take TB treatment? Yes Date started: No TB symptom review If positive TB test, most recent chest x-ray? Date Result 2-step required: Yes No
Volunteer signature / Date
Employee Health Reviewer / Date
PARENT PERMISSION FOR MINORS: (VOLUNTEERS UNDER 18 YEARS OF AGE)
My (our) daughter/son has permission to participate in Harborview Medical Center’s Volunteer Program. The date of her/his most recent Tuberculin test skin test was __________. I (We) authorize Harborview Medical Center to give my daughter/son a Tuberculin skin test before the beginning of her/his Volunteer assignment.
Name of Parent or Guardian
Signature of Parent or Guardian
Date
REV: Feb2009
Harborview Medical Center - Employee Health Center
Definitions and criteria for current immune status for
Name
Last - First - MI
Employee Health Center 325 Ninth Avenue, Box 359855 Seattle, Washington 98104
Social Security Number or EID :
* REQUIRED *
Home address
Street - City - State - Zip Code
Date of birth
Month - Date - Year
Gender:
Home (
M
F
)
Telephone Department
Comments :
)
Cell (
HMC VOLUNTEERS
Job Title VOLUNTEER
Box Number 359788
Date began Yes No
Will you have possible exposure to blood or body fluids in your volunteer position?
Please fill non-shaded areas below. Shaded areas are office use. See reverse side for defining criteria and requirements.
Communicable disease immunization history
Disease Hepatitis B Measles (Rubeola) Mumps Rubella (3-day measls) MMR
Tetanus / Td / Tdap
Have you had this disease?
WBR Vaccination dates
UTD
ROI Antibody testing
Date of titer To lab
Yes / No
Dose 1
Dose 2
Dose 3
Most recent
Result (Pos / Neg)
Office use only
Varicella (chickenpox) Other: Other:
Tuberculosis screening
BCG vaccinated? Yes No Unknown Today's date: Last TB skin test Date Result TB skin test If positive TB test, did you take TB treatment? Yes Date started: No TB symptom review If positive TB test, most recent chest x-ray? Date Result 2-step required: Yes No
Volunteer signature / Date
Employee Health Reviewer / Date
PARENT PERMISSION FOR MINORS: (VOLUNTEERS UNDER 18 YEARS OF AGE)
My (our) daughter/son has permission to participate in Harborview Medical Center’s Volunteer Program. The date of her/his most recent Tuberculin test skin test was __________. I (We) authorize Harborview Medical Center to give my daughter/son a Tuberculin skin test before the beginning of her/his Volunteer assignment.
Name of Parent or Guardian
Signature of Parent or Guardian
Date
REV: Feb2009
Harborview Medical Center - Employee Health Center
Definitions and criteria for current immune status for