EMPLOYEE VACCINATION RECORD

Name of Employee:

Date of Joining :

DATE
Sl.No. VACCINATION DOSAGE / BATCH NO.
ADMINISTERED ON

1ST

2ND
(AFTER 01 MONTH)
1 HEPATITIS B
3RD
(AFTER 06 MONTH)

2 TETANUS DOSE 1

UNDERTAKING
I Dr/Mr./Mrs./ Ms …………………………………….SO/DO/WO ……………………… am fully vaccinated against Hepatitis B

/Tetanus on following dates.

S.N. VACCINATION DOSAGE ADMINISTERED ON DATE

1ST
2ND
1 HEPATITIS B
3RD
BOOSTER
 2 TETANUS DOSE

HR HEAD/ MD
CORD
Department:

Date of Birth/Age:

DATE
SIGNATURE OF DMO
NEXT DUE

gainst Hepatitis B

EMPLOYEE SIGNATURE
SIGNATURE