CONFIDENTIAL

New Jersey Department of Health

PEOSH Unit

HEPATITIS B VACCINE IMMUNIZATION RECORD

Vaccine is to be Administered on:
Elected Dates:
First:
One Month from Elected Date:
Six Months from Elected Date:
Name of Employee:
Date of First Dose:
Date of Second Dose:
Date of Third Dose:
Antibody Test Results – Pre-vaccine (Optional):
Antibody Test Results – Post-Vaccine:
Time Interval Since Last Injection:
Signature of Employee:
Date:

OCC-6

JAN 13

OCC-

OCT 08	29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This log must be kept in addition to the injury and illness log required by 29 CFR 1904. The Sharps Injury Log should include all sharps injuries occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a manner that preserves the confidentiality of the affected employee.

OCC-6, Hepatitis B Vaccine Immunization Record

occ-6, hepatitis b, vaccine, immunization record, PEOSH, occupational, occ

ewhite

2009-02-24

NJDOH