NAVMED Form 6000/5 "Vaccine Screening Questionnaire"

NAVMED Form 6000/5 Printable Pdf
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What Is NAVMED Form 6000/5?

This is a legal form that was released by the U.S. Department of the Navy - Navy Medicine on September 1, 2008 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2008;
  • The latest available edition released by the U.S. Department of the Navy - Navy Medicine;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of NAVMED Form 6000/5 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Navy - Navy Medicine.

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Download NAVMED Form 6000/5 "Vaccine Screening Questionnaire"

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MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA
For use of this form, see requiring document. Form is not valid without Requiring Document, Issuance Date, Local Form Number, and Edition Date.
REQUIRING DOCUMENT
LOCAL FORM TITLE
ISSUANCE DATE
Vaccine Screening Questionnaire
NAVMEDCENPTSVA INST
July 2011
6230.3a w/ch1
NMCP 6230/4 (NEW 7/11) Exception to NAVMED 6000/5 (09/2008)
Date
ADENOVIRUS, ANTHRAX, BCG, DTAP, HEPATITIS A, HEPATITIS B, HIB, HPV, INFLUENZA (INACTIVATED / FLUMIST ),
JEV, MMR, MENINGOCOCCAL, PNEUMOCOCCAL (PNEUMOVAX / PREVNAR) POLIO, PPD, RABIES, ROTAVIRUS, TD,
TDAP, TT, TYPHOID Vi, TYPHOID ORAL TABS, VARICELLA, YELLOW FEVER, ZOSTAVAX
( LIVE VIRUSES ARE BOLDED)
Do you have a weakened immune system because of drug treatment for organ transplant, cancer, rheumatology condition
1)
Yes / No
(RA, Lupus, etc), Multiple Sclerosis, or HIV/AIDS or another disease that affects the immune system?
2)
Have you been taking oral steroids for greater than two weeks?
Yes / No
3) If less than 21 years old – are you taking daily aspirin therapy? (specifically for Varicella and Influenza vaccine)
Yes / No / NA
4)
Do you have a febrile illness (with a fever greater than 101)? If yes, delay vaccination.
Yes/No
Are you, or do you think you may be, pregnant?
Yes / No / NA
5)
If Yes, the only vaccine routinely administered without a specialist order is injectable Influenza, PPD skin test.
Unknown
Have you received any other LIVE vaccinations in the past 4 weeks?
Yes / No
6)
Have you received any blood product in the last 6 months?
Yes / No
If yes to any of the above, do not administer ANY live vaccine under routine immunization practice.
Print the names of your CURRENT MEDICATIONS, including over-the-counter and homeopathic remedies.
r No change or contraindications from SF-508
Medications reconciled by: _____________________
Do you have long-term health problems with: heart disease, lung disease, asthma, kidney disease, metabolic disease
7)
(e.g. diabetes), anemia, neurological disorders and other blood disorders? If yes, DO NOT administer FluMist, follow
Yes / No
Injectable Flu Vaccine protocol. If seizures reported in children the PCM must review prior to DTaP.
Are you 50 years of age or older or a child 6 months to 2 years of age?
8)
Yes / No
If Yes, follow protocol for administering Injectable Flu Vaccine.
Have you ever had Guillain-Barré Syndrome (a severe paralytic illness, also called GBS)?
9)
Yes / No
If Yes, DO NOT administer flu, send to provider to evaluate prior to administering Menactra.
Do you have a vaccine component allergy? Such as Thimerosal, latex, gelatin, yeast, Streptomycin, Neomycin, phenol,
10)
or egg, etc. If yes, DO NOT administer vaccine that contains any of the above components.
Yes / No
If yes, refer to PCM for clarification, documentation and validation of allergy on file.
Have you ever had a serious reaction to a vaccine in the past that required medical treatment?
11)
Yes / No
If yes, refer to PCM for clarification, documentation and validation of VAER’s filed.
Have you read or have you had the Vaccine Information Statement (VIS) explained to you?
12)
Yes / No
Have you had a chance to ask questions and have they been answered to your satisfaction?
Have you had an allergy shot today? If yes, delay vaccination (interval should be at least 24 hours). Or are you
13)
Yes / No
scheduled to receive allergy therapy within the next 24 hours? (interval should be at least 24 hours).
14)
Have you ever had a positive PPD?
Yes / No
PRACTITIONER'S NAME
DATE
PRACTITIONER'S SIGNATURE
PATIENT'S IDENTIFICATION: (For typed or written entries, give:
HOSPITAL OR MEDICAL FACILITY
STATUS
Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)
DEPARTMENT / SERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN
RELATIONSHIP TO SPONSOR
NAVMED 6000/5 (09-2008)
Category
Page 1 of 2
MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA
For use of this form, see requiring document. Form is not valid without Requiring Document, Issuance Date, Local Form Number, and Edition Date.
REQUIRING DOCUMENT
LOCAL FORM TITLE
ISSUANCE DATE
Vaccine Screening Questionnaire
NAVMEDCENPTSVA INST
July 2011
6230.3a w/ch1
NMCP 6230/4 (NEW 7/11) Exception to NAVMED 6000/5 (09/2008)
Date
ADENOVIRUS, ANTHRAX, BCG, DTAP, HEPATITIS A, HEPATITIS B, HIB, HPV, INFLUENZA (INACTIVATED / FLUMIST ),
JEV, MMR, MENINGOCOCCAL, PNEUMOCOCCAL (PNEUMOVAX / PREVNAR) POLIO, PPD, RABIES, ROTAVIRUS, TD,
TDAP, TT, TYPHOID Vi, TYPHOID ORAL TABS, VARICELLA, YELLOW FEVER, ZOSTAVAX
( LIVE VIRUSES ARE BOLDED)
Do you have a weakened immune system because of drug treatment for organ transplant, cancer, rheumatology condition
1)
Yes / No
(RA, Lupus, etc), Multiple Sclerosis, or HIV/AIDS or another disease that affects the immune system?
2)
Have you been taking oral steroids for greater than two weeks?
Yes / No
3) If less than 21 years old – are you taking daily aspirin therapy? (specifically for Varicella and Influenza vaccine)
Yes / No / NA
4)
Do you have a febrile illness (with a fever greater than 101)? If yes, delay vaccination.
Yes/No
Are you, or do you think you may be, pregnant?
Yes / No / NA
5)
If Yes, the only vaccine routinely administered without a specialist order is injectable Influenza, PPD skin test.
Unknown
Have you received any other LIVE vaccinations in the past 4 weeks?
Yes / No
6)
Have you received any blood product in the last 6 months?
Yes / No
If yes to any of the above, do not administer ANY live vaccine under routine immunization practice.
Print the names of your CURRENT MEDICATIONS, including over-the-counter and homeopathic remedies.
r No change or contraindications from SF-508
Medications reconciled by: _____________________
Do you have long-term health problems with: heart disease, lung disease, asthma, kidney disease, metabolic disease
7)
(e.g. diabetes), anemia, neurological disorders and other blood disorders? If yes, DO NOT administer FluMist, follow
Yes / No
Injectable Flu Vaccine protocol. If seizures reported in children the PCM must review prior to DTaP.
Are you 50 years of age or older or a child 6 months to 2 years of age?
8)
Yes / No
If Yes, follow protocol for administering Injectable Flu Vaccine.
Have you ever had Guillain-Barré Syndrome (a severe paralytic illness, also called GBS)?
9)
Yes / No
If Yes, DO NOT administer flu, send to provider to evaluate prior to administering Menactra.
Do you have a vaccine component allergy? Such as Thimerosal, latex, gelatin, yeast, Streptomycin, Neomycin, phenol,
10)
or egg, etc. If yes, DO NOT administer vaccine that contains any of the above components.
Yes / No
If yes, refer to PCM for clarification, documentation and validation of allergy on file.
Have you ever had a serious reaction to a vaccine in the past that required medical treatment?
11)
Yes / No
If yes, refer to PCM for clarification, documentation and validation of VAER’s filed.
Have you read or have you had the Vaccine Information Statement (VIS) explained to you?
12)
Yes / No
Have you had a chance to ask questions and have they been answered to your satisfaction?
Have you had an allergy shot today? If yes, delay vaccination (interval should be at least 24 hours). Or are you
13)
Yes / No
scheduled to receive allergy therapy within the next 24 hours? (interval should be at least 24 hours).
14)
Have you ever had a positive PPD?
Yes / No
PRACTITIONER'S NAME
DATE
PRACTITIONER'S SIGNATURE
PATIENT'S IDENTIFICATION: (For typed or written entries, give:
HOSPITAL OR MEDICAL FACILITY
STATUS
Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)
DEPARTMENT / SERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN
RELATIONSHIP TO SPONSOR
NAVMED 6000/5 (09-2008)
Category
Page 1 of 2
MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA
For use of this form, see requiring document. Form is not valid without Requiring Document, Issuance Date, Local Form Number, and Edition Date.
Date
PATIENT / PARENT SIGNATURE - Patient / Parent has been instructed on possible side effects and
post immunization care. Required VIS forms have been provided to the patient / parent.
Yes / No
Signature of Patient / Parent:__________________________
Stamp & signature of interviewer/vaccinator:
Actions taken / medication administered:
Immunocompromised Vaccination Guidance Table
Symptomatic
Severly
Post-Solid Organ
Chronic Hepatic
Asymptomatic
Renal
Vaccine Type
HIV Infection
Immunocompromised
Transplant / Chronic
Asplenia
Disease, Cirrhosis,
HIV
Failure
/ AIDS
(Non-HIV Related)
Immunosuppressive Therapy
Diabetes
Live Vaccines
Bacille Calmette Guérin
X
X
X
X
U
U
U
X
X
X
X
X
X
Influenza (LAIV)
U
W
MMR (MR/M/R) [1]
R
X
X
U
U
U
Rotavirus
X
X
X
X
X
X
U
Typhoid, Ty21a
X
X
X
X
U
U
U
Varicella [2]
U
X
X
X
U
U
U
W
Yellow Fever [3]
X
X
X
U
U
U
Smallpox
X
X
X
X
U
X
U
Killed (Inactivated) Vaccines
Anthrax
U
U
U
U
U
U
U
Haemophilus
C [4]
C [4]
R
R
R
U
U
Influenzae (HIB)
Hepatitis A
U [5]
U [5]
U
U
U [5]
U [5]
U [5]
Hepatitis B
U [5]
U [5]
U
U
U
R [6]
U
Influenza (inactivated)
R
R
R
R
R
R
R
Japanese encephalitis
U
U
U
U
U
U
U
Meningococcal polysaccharide or
C
C
U
U
R
U
U
conjugate
Pneumococcal polysaccharide or
R
R
R
R
R
R
R
conjugate
Polio (IPV)
U
U
U
U
U
U
U
Rabies
U
U
U
U
U
U
U
Td or Tdap, Dtap
R
R
R
R
R
R
R
Typhoid, Vi
U
U
U
U
U
U
U
C = Consider W = Warning
Legend:
R = Recommended for all in this category
U = Use as indicated for normal hosts
X = Contraindicated
[1] MMR vaccination should be considered for all symptomatic HIV-infected persons with CD4 counts >200/mL without evidence of measles immunity. Immune globulin may be
administered for short-term protection of those facing high risk of measles and for whom MMR vaccine is contraindicated.
[2] Varicella vaccine should not be administered to persons who have cellular immunodeficiencies, but persons with impaired humoral immunity (including congenital or acquired
hypo- or dysglobulinemia) may be vaccinated. Immuncompromised hosts should receive two doses of vaccine spaced at 3-month intervals.
[3] Yellow fever vaccine. See detail in text.
[4] Decision should be based on consideration of the individual patient’s risk of Hib disease and the effectiveness of the vaccine for that person. In some settings, the incidence of Hib
disease may be higher among HIV-infected adults than non-HIV-infected adults, and the disease can be severe in these patients.
[5] Routinely indicated for all men who have sex with men, persons with multiple sexual partners, hemophiliacs, patients with chronic hepatitis, and injection drug users.
[6] Use special double-dose vaccine formulation. Test for anti-Hbs response after vaccination and revaccinate if initial response is absent.
http://wwwn.cdc.gov/travel/yellowBookCh9-Immunocompromised.aspx
Privacy Act Statement. AUTHORITY: Title 10 U.S. Code §§ 5014 and 5020 PURPOSE: To document vaccination administration in the health record. Disclosure of Social Security
Account Number is voluntary; however it is necessary to document vaccination in the Health Record to be in compliance with 42 U.S. Code. It is further identify the individual providing
the information and receiving the care. It is important that the information be correct. Incorrect information could result in documentation, reporting and payment errors. Incorrect
information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the agency to
provide you services. THIS STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USED TO RELEASE OR TO USE YOUR HEALTH CARE INFORMATION.
PRACTITIONER'S NAME
DATE
PRACTITIONER'S SIGNATURE
PATIENT'S IDENTIFICATION: (For typed or written entries, give:
HOSPITAL OR MEDICAL FACILITY
STATUS
Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)
DEPARTMENT / SERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN
RELATIONSHIP TO SPONSOR
NAVMED 6000/5 (09-2008)
Category
Page 2 of 2
Health Screening Form U.S. Department of the Navy - Navy Medicine Medical Forms Medical United States Federal Legal Forms United States Legal Forms

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