Hepatitis B Vaccination and
Post-Vaccination Serology Results
Pediatric provider: Please complete this form each time the child named below receives a
hepatitis B vaccination and post-vaccination serology and fax to the number below.
Public Health Agency: _________________________________________
Case Coordinator: ____________________________________________
Phone Number: _________________ Fax Number: __________________
Child Name: ___________________________________________
Child DOB: ___________________________________________
Mother Name: _________________________________________
Mother DOB: __________________________________________
Hepatitis B Vaccination
Vaccine
Date
(Circle)
HBIG
---------
(LPH complete)
Heb B 1
(LPH complete)
Engerix
Recombivax
Engerix
Pediarix
Hep B 2
Recombivax
Engerix
Pediarix
Hep B 3
Recombivax
Engerix
Pediarix
Hep B 4
Recombivax
Post-Vaccination Serology Results
Serology test
Date
(Circle)
HBsAg
Positive
Negative
Anti-HBs
Positive
Negative
Form completed by: _____________________________________
Clinic name: ___________________________________________
Phone number: _________________________________________
Should you have questions, please feel free to contact me at the number above.
Thank you for your assistance.