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 |
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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 |
H511.340 (Rev. 4/00) |
Position ____________________________ |
COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA DEPARTMENT OF HEALTH
SCHOOL PERSONNEL HEALTH RECORD
I. Patient Information
Last Name |
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First |
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Sex |
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Date of Birth |
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Social Security Number |
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Home Telephone |
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Work Telephone |
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Mailing Address |
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Street |
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City |
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State |
Zip |
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Usual Source of Medical Care |
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Physician’s Name |
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Address |
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Telephone |
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Emergency Contact – Name |
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Relationship |
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Address |
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Telephone |
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II. Immunization History |
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Enter Month, Day, and Year Each Immunization was Given |
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VACCINE |
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DOSES |
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BOOSTERS & DATES |
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Diphtheria and Tetanus* |
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1. |
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2. |
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3. |
4. |
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5. |
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Hepatitis B |
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1. |
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2. |
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3. |
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Measles, Mumps, Rubella |
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1. |
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2. |
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Other ________________ |
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1. |
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Other _____________________ |
1. |
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*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 |
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DATE READ
RESULTS (mm)
SIGNATURE
For previously known/new positive reactors: _______________________________________________________________________
Chest |
Date: ____________ Results: _____________ |
Other: |
Date: _____________ Results: _______________ |
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(Attach a copy of the report.) |
(Attach a copy of the report.) |
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Preventive |
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 ( ) |
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Yes |
No |
If Yes, Explain: |
Allergies |
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Asthma |
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Cardiac |
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___________________________________________________________________ |
Chemical Dependency |
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___________________________________________________________________ |
Drugs |
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___________________________________________________________________ |
Alcohol |
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___________________________________________________________________ |
Diabetes Mellitus |
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___________________________________________________________________ |
Gastrointestinal Disorder |
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___________________________________________________________________ |
Hearing Disorder |
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___________________________________________________________________ |
Hypertension |
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___________________________________________________________________ |
Neuromuscular Disorder |
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___________________________________________________________________ |
Orthopedic Condition |
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___________________________________________________________________ |
Respiratory Illness |
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___________________________________________________________________ |
Seizure Disorder |
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___________________________________________________________________ |
Skin Disorder |
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___________________________________________________________________ |
Vision Disorder |
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___________________________________________________________________ |
Other (Specify) |
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V. Report of Physical Examination ( )
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NORMAL |
ABNORMAL |
NOT |
COMMENTS |
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EXAMINED |
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Height (inches) ______________ |
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Weight (pounds) ______________ |
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Pulse _____________ |
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Blood Pressure ______________ |
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Hair/Scalp |
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Skin |
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Eyes – Visual Acuity: R _____ L _____ |
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Eyes – Color Vision |
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Ears – Hearing (dB) R _____ L _____ |
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Nose and Throat |
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Teeth and Gingiva |
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Lymph Glands |
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Heart – Murmur, etc… |
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Lungs – Adventitous Findings |
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Abdomen |
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Genitourinary |
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Neuromuscular System |
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Extremities |
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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.
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_____________________ |
Signature of Employee |
Date |