Ameya Clinic

DAILY OBSERVATION
A Unit of Vartak Health Services Pvt Ltd

Name of Employee Department

Date of Joining Designation

No Vaccination
Enough Antibodies
Required
Decision Matrix (HBV Inadequate
Vaccination) Yes Antibody Titre
Antibodies
Start Vaccination
History of
Vaccination Inderminate Repeat Antibody
No Start Vaccination
Antibidies test

Remark of Previous Vaccination

Name of Vaccine Remark Recorded By (Name, Sign / Date)
HBV (Hepatitis B
Vaccine)
Tetanus Vaccine

Schedule (Utilise
Name of Antibody Titre Date of Dose Given by (Name,
Insert to Mention the
Vaccine (If Applicable) Dose Sign / Date)
Schedule)
Name:
First Dose: Qualification:

(__________) Sign:
Date:
Name:
Second Dose:
HBV (Hepatitis B Qualification:
Vaccine) (__________) Sign:
Date:
Name:
Third Dose: Qualification:

(__________) Sign:
Date:

Tetanus Vaccine

Version SRKH/001 Document Number SRKH/SOP/DPT/001

Effective Date 4 Sept 2018 Revision Date 3 Sept 2018