Form H511 340 – Fill Out and Use This PDF

Form H511 340 is an important legal document used to submit a formal request for water service. Its official designation classifies it as part of the organizing regulations or rules in accordance with Chapter 60G-6 forms from Florida statutes. This form grants applicants official access to implement the use of public resources and modifications for private domestic uses. It contains the proper drafts, basics sections, notations, information requirements, declarations and fees that must be supported throughout the process. This document plays a critical role in many daily operations involving water resources; therefore its presence must be acknowledged systematically.

Form H511 340 PDF Details

In order to best protect your health, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires certain federally-mandated notices be delivered to individuals. The Form H511 340 is one such notice, informing individuals about their privacy rights and how their protected health information may be used and disclosed. By understanding your HIPAA rights, you can take steps to safeguard your personal information. Review the Form H511 340 now to learn more.

Question	Answer
Form Name	Form H511 340
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	pa school personnel health record form, DTP, PENNSYLVANIA, Adventitous

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H511.340 (Rev. 4/00)

Position ____________________________

COMMONWEALTH OF PENNSYLVANIA

PENNSYLVANIA DEPARTMENT OF HEALTH

SCHOOL PERSONNEL HEALTH RECORD

I. Patient Information

Last Name		First		MI		Sex		Date of Birth

Social Security Number				Home Telephone				Work Telephone

Mailing Address		Street			City			State	Zip

Usual Source of Medical Care		Physician’s Name			Address			Telephone

Emergency Contact – Name		Relationship			Address			Telephone
II. Immunization History


		Enter Month, Day, and Year Each Immunization was Given
VACCINE			DOSES				BOOSTERS & DATES
Diphtheria and Tetanus*	1.		2.		3.	4.		5.

Hepatitis B	1.		2.		3.
Measles, Mumps, Rubella	1.		2.
Other ________________	1.		Other _____________________			1.

*Tetanus and Diphtheria are usually received in combined vaccines such as DTP, DtaP, DT, or Td

III. Required Tuberculosis Test Results (as per Regulations of the Department of Health

DATE APPLIED	ARM	METHOD	ANTIGEN	MANUFACTURER	SIGNATURE

DATE READ

RESULTS (mm)

SIGNATURE

For previously known/new positive reactors: _______________________________________________________________________

Chest X-ray:	Date: ____________ Results: _____________	Other:	Date: _____________ Results: _______________
(Attach a copy of the report.)		(Attach a copy of the report.)
Preventive Anti-Tuberculosis Chemotherapy ordered:		No	Yes	Date: ______________

IF SIGNIFICANT REACTION WAS REPORTED, THE PHYSICIAN REPORT MUST STATE THAT THE APPLICANT IS FREE FROM CURRENT TUBERCULOSIS DISEASE OR IS UNDER ADEQUATE CHEMOTHERAPY FOR TUBERCULOSIS DISEASE:

___________________________________________________________________________________________________________________

IV. Significant Medical Conditions ( )

Yes	No	If Yes, Explain:
Allergies		___________________________________________________________________
Asthma		___________________________________________________________________
Cardiac		___________________________________________________________________
Chemical Dependency		___________________________________________________________________
Drugs		___________________________________________________________________
Alcohol		___________________________________________________________________
Diabetes Mellitus		___________________________________________________________________
Gastrointestinal Disorder		___________________________________________________________________
Hearing Disorder		___________________________________________________________________
Hypertension		___________________________________________________________________
Neuromuscular Disorder		___________________________________________________________________
Orthopedic Condition		___________________________________________________________________
Respiratory Illness		___________________________________________________________________
Seizure Disorder		___________________________________________________________________
Skin Disorder		___________________________________________________________________
Vision Disorder		___________________________________________________________________
Other (Specify)		___________________________________________________________________

V. Report of Physical Examination ( )

	NORMAL	ABNORMAL	NOT	COMMENTS
	NORMAL	ABNORMAL	EXAMINED	COMMENTS
			EXAMINED
Height (inches) ______________

Weight (pounds) ______________
Pulse _____________

Blood Pressure ______________

Hair/Scalp

Skin
Eyes – Visual Acuity: R _____ L _____

Eyes – Color Vision

Ears – Hearing (dB) R _____ L _____
Nose and Throat

Teeth and Gingiva

Lymph Glands

Heart – Murmur, etc…

Lungs – Adventitous Findings

Abdomen

Genitourinary

Neuromuscular System

Extremities

Are there any special medical problems or chronic diseases which require restriction of activity, medication or which might affect his/her work role? If so, specify __________________________________________________________________________________

____________________________________________	__________________________________________________	___________________
Physician Name (Print)	Signature of Examiner	Date

______________________________________________________________________________________________________________________________

Physician Address

The statements and answers as recorded above are full, complete and true to the best of my knowledge and belief. I understand that any false or misleading statements may cause termination of my employment.

I authorize the physician or other person to disclose any knowledge or information pertaining to my health to the employing authority for whom this examination is performed.

_________________________________________	_____________________
Signature of Employee	Date

Form H511 340 – Fill Out and Use This PDF

Form H511 340 PDF Details

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