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IMMUNIZATION HISTORY CERTIFICATION Name: Date of Birth: Department: Position (Please circle ONE) Volunteer Intern Student Temp Agency Other: Welcome to St Luke's Hospital & Health Network (SLAIN).

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1. Start by opening the intern-immunhstrydoc form.
2. Fill in your personal information, such as your name, date of birth, and contact information.
3. Provide information about your medical history, including any allergies, medications you are currently taking, and any previous immunizations you have received.
4. If you have had any previous adverse reactions to vaccines, make sure to note this in the appropriate section of the form.
5. Indicate whether you have any chronic medical conditions or if you are currently pregnant or breastfeeding.
6. If you have recently traveled internationally, mention the countries you have visited and any special precautions or vaccines you may have received.
7. Sign and date the form to certify that the information you have provided is accurate.
8. Keep a copy of the completed intern-immunhstrydoc for your records.

Who needs intern-immunhstrydoc:

1. Individuals who are starting an internship or training program in a healthcare or medical-related field may be required to fill out the intern-immunhstrydoc form.
2. This form is often necessary to ensure that individuals have received the necessary immunizations and do not have any medical conditions that may put them or others at risk.
3. Employers or training institutions may request this form to maintain the health and safety of their staff and patients.
4. It is important to consult with your specific internship or training program to determine if you need to fill out the intern-immunhstrydoc form.

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