Bloodborne Pathogens Exposure Control

Hepatitis B Immunization Record

for

______________________________________________
Employee Name

______________________________________________
Social Security Number

_______________________________________________
Job Title


Initial Dose of:____________________________________

given______________________	by_____________________________




Second Dose of: _____________________________________

given______________________	by______________________________
   (30 days after initial)



Third Dose of: _____________________________________

given______________________ by_____________________________
   (6 months after initial)

Updated November 20, 2007 by SAK