Volunteer Handbook - Roper St. Francis Healthcare

Employee Health DepartmentRoper Monday-Friday 7:30-4St. Francis Tuesday & Thursday 7:30-4Phone (843) 724-2131 Fax (843) 724-1325Immunization Review and PPD FormName SSN - -________Signature Date / /________Guardian Signature (For minors) Date / /________Work Phone Home Phone Cell Phone _____________________ Roper Hospital St. Francis Hospital Roper Berkeley Other:Immunization Review: Check All That ApplyIf you do not have documentation, a blood draw will be done to check for immunity.Vaccination will be discussed based on documentation, immunity test results and personal risk factors.Hepatitis B Vaccine (HBV) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I do not know if I have had Hepatitis B Vaccination. I have not had Hepatitis B Vaccination.Rubeola Vaccine (Red Measles) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I do not know if I have had Rubeola Vaccination. I have not had Rubeola Vaccination.Rubella (German Measles) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I do not know if I have had Rubella Vaccination. I have not had Rubella Vaccination.Varicella-Zoster (Chickenpox, Shingles) Proof of immunity (titer). You must have document. Proof of vaccination. You must have document. I can report a reliable history of chickenpox or shingles. I do not know if I have had Varicella Illness or Vaccination. I have not had Varicella Illness or VaccinationTuberculosis ScreeningTwo PPDs are required before starting as a volunteer. If you had a TB skin test within the last 12 months bring the documentation.An annual PPD is required for those who continue on as volunteers.If you have ever tested positive to a TB skin test bring the documentation and your most recent chest x-ray.TB Tests need to be read between 48–96 hours. If the test is not read by 96 hours it must be repeated.One TB skin test must be read in the Employee Health Office. Bring a copy of your completed results to the Volunteer Office.What was the result your last PPD skin test?Have you ever been exposed to anyone with TB?Do you have Leukemia, Lymphoma, or another cancer?Have you been told that you have a disease of the immune system?Have you experienced an unexplained weight loss?Do you feel fatigued most of the time?Have you had a recent fever?Do you have night sweats?Do you have a persistent cough (dry, wet or bloody)?POSITIVEYesYesYesYesYesYesYesYesEMPLOYEE HEALTH STAFF USE ONLYNegativeNoNoNoNoNoNoNoNoSanofi Pasteur Lot # ____________ Exp. Date ______/______/_______ Site: LFA ____ RFA ____PPD planted _____/_____/_____ Planted by: __________________________________PPD read _____/_____/_____ Read by: ____________________________________UnsureUnsureUnsureUnsureUnsureUnsureUnsureUnsureUnsureResult ____________ (mm) (A Positive result is >/= 10 mm, or > 5 mm in an immunosuppressed person)Sanofi Pasteur Lot # ____________ Exp. Date ______/______/_______ Site: LFA ____ RFA ____PPD planted _____/_____/_____ Planted by: __________________________________PPD read _____/_____/_____ Read by: ____________________________________[] Entered ________[] Entered ________[] Entered ________[] Entered ________Result ____________ (mm) (A Positive result is >/= 10 mm, or > 5 mm in an immunosuppressed person) Past positive. No PPD skin testing required. Staff signature:Date: ____/____/_____ CXR: + PPD CXR: + Symptoms CXR: Past Positive CCHD Referral HBV Completed HBV Declined HBV Needed - Recall HBV Contraindicated RUBELLA Completed RUBELLA Declined RUBELLA Needed - Recall RUBELLA Contraindicated RUBEOLA Completed RUBEOLA Declined RUBEOLA Needed - Recall RUBEOLA Contraindicated VAR Completed VAR Declined VAR Needed - Recall VAR ContraindicatedC:\Documents and Settings\jperry\Local Settings\Temporary Internet Files\OLKD20\Volunteer Immunization and PPD Form.doc1/25/2008EnterAllIMM