Nursing Home Staff
Vaccination Record Form
This form is to be completed by all staff members to document their vaccination status as part of our health and safety protocols. Please fill out the form accurately and return it to the designated health office within our facility.
Staff Member Information
Name | | Position | |
Department | | Submission Date | |
Vaccination Details
Please provide the following details for each vaccination received. Include all vaccinations required by our health protocols as well as any additional relevant vaccinations.
Vaccine Type | Brand | Date Received | Dose | Administered By |
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Medical Exemptions
If you have any medical exemptions for specific vaccines, please provide a detailed explanation and attach supporting documentation from a healthcare provider.
Vaccine Type | Reason for Exemption |
|---|
| |
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Consent and Declaration
I hereby certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand the importance of vaccinations in preventing disease transmission within our facility and commit to maintaining up-to-date vaccination records as required.
Signatures
Staff Member
[Name]
[Date]
Reviewer
[Name]
[Date]
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