department of athletics policies & procedures - UNC Wilmington ...

FORM C:
THE UNIVERSITY OF NORTH CAROLINA WILMINGTON
DEPARTMENT OF ATHLETIC TRAINING
MANDATORY HEPATITIS B VACCINATION RECORD FORM
Name (print):_______________________ Title: _____________________
1 st Vaccination date: ________________
Location (if known):_____________________________
2 nd Vaccination date: ________________
Location (if known):_____________________________
3rd Vaccination date: ________________
Location (if known):_____________________________
Please provide any Dr.’s notes and/or other documentation received when you
obtained these vaccination shots.
Signature: ___________________________________________________
Director of Athletic Training signature: ___________________________
Date: ____________________________
This form pertains to the requirements of the OSHA Standard on Occupational Exposure
to Blood borne Pathogens as appears in the Federal Register, December 6, 1991, 29 CFR
Part 1910.1030.
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