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Template: Medical Intake
Immunization Record for Occupational Health
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Collect immunization records from employees for occupational health purposes.
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Full Name
*
Date of Birth
*
Position/Job Title
Date of Submission
*
Have you received the following immunizations? Please provide the most recent dates.
Do you have documented proof of these immunizations?
*
Yes
No
Upload Immunization Documents (if available)
Are there any other relevant vaccines you have received?
Additional Comments
Signature of Employee
*
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