Page 1 of 3
Patient name Tyeisha Howard
Birthdate 11/19/1994 Axion ID 20418425
PRACTICE NAME AND ADDRESS
Vaccination and Surveillance Record
ILARL-RESURRECTION
Print Date: 01/31/24 10:13 AM 7447 W. Talcott Ave., Suite 242
CHICAGO,IL 60631
Vaccine Information
Given / Vaccine Statement (VIS)
Dose Admin'd /
Charting Form Performed By Product / Titer Status Complete Provider / Clinic
Result
Date
Lot # Manufacturer Exp_Date VIS Date
Flu Program Surveillance
SEASONAL FLU VACCINATION RECORD AS PART OF THIS ENCOUNTER Afluria Quadrivalent GIVEN 10/05/23 Zerina Jusic RN AU1037A Seqirus 05/31/24 08/06/21
Hepatitis B Surveillance
HEPATITIS B IMMUNIZATION RECORD RECEIVED ELSEWHERE Prior First Dose 12/31/94
HEPATITIS B IMMUNIZATION RECORD RECEIVED ELSEWHERE Prior Second Dose 03/19/95
HEPATITIS B IMMUNIZATION RECORD RECEIVED ELSEWHERE Prior Third Dose 06/06/95
HEPATITIS B IMMUNIZATION RECORD RECEIVED ELSEWHERE Third Dose 06/06/95
HEPATITIS B IMMUNIZATION RECORD NOT PERFORMED - DECLINED 10/13/23
HEPATITIS B VIRUS
NOT
HEPATITIS B TITER RECORD EHS AS PART OF THIS ENCOUNTER SURFACE ANTIBODY Negative 10/05/23
IMMUNE
(ANTI-HBS)
MMR Surveillance
MEASLES, MUMPS, AND RUBELLA (MMR) Prior MMR First Dose
RECEIVED ELSEWHERE 11/28/95
IMMUNIZATION RECORD
MEASLES, MUMPS, AND RUBELLA (MMR) Prior MMR Second
RECEIVED ELSEWHERE 09/19/99
IMMUNIZATION RECORD Dose
MEASLES, MUMPS, AND RUBELLA (MMR)
RECEIVED ELSEWHERE Second Dose 03/19/99
IMMUNIZATION RECORD
TB Surveillance
When the Vaccination and Surveillance Report is given to the patient, sharing this information is at the patient's sole discretion.
Page 2 of 3
Patient name Tyeisha Howard
Birthdate 11/19/1994 Axion ID 20418425
PRACTICE NAME AND ADDRESS
Vaccination and Surveillance Record
ILARL-RESURRECTION
Print Date: 01/31/24 10:13 AM 7447 W. Talcott Ave., Suite 242
CHICAGO,IL 60631
Vaccine Information
Given / Vaccine Statement (VIS)
Dose Admin'd /
Charting Form Performed By Product / Titer Status Complete Provider / Clinic
Result
Date
Lot # Manufacturer Exp_Date VIS Date
IGRA AS PART OF THIS ENCOUNTER Negative 10/10/23
No Symptoms
TUBERCULOSIS (TB) SYMPTOM REVIEW AS PART OF THIS ENCOUNTER 10/05/23
Present
Tetanus Surveillance
TETANUS, DIPHTHERIA, AND PERTUSSIS
RECEIVED ELSEWHERE Booster 10/31/19
(TDAP) IMMUNIZATION RECORD
Varicella Surveillance
VARICELLA ZOSTER
VARICELLA (CHICKENPOX) TITER RECORD EHS AS PART OF THIS ENCOUNTER Positive IMMUNE 10/05/23
VIRUS ANTIBODY IGG
Service /
Charting Form Performed By Type Result Provider / Clinic
Complete Date
Health Assessment Surveillance
HEALTH ASSESSMENT RESULT SUMMARY Passed 10/05/23 Zerina Jusic RN
Respirator Surveillance
RESPIRATOR FIT TESTING AS PART OF THIS ENCOUNTER N95 Pass 10/05/23
FILTER-MASK NON-CARTRIDGE (N,
RESPIRATOR USER MEDICAL CLEARANCE Cleared 10/05/23
R, OR P DISPOSABLE) (N95)
RESPIRATOR USER TRAINING AS PART OF THIS ENCOUNTER N95 N95 10/05/23 Zerina Jusic RN
Toxicology Surveillance
When the Vaccination and Surveillance Report is given to the patient, sharing this information is at the patient's sole discretion.
Page 3 of 3
Patient name Tyeisha Howard
Birthdate 11/19/1994 Axion ID 20418425
PRACTICE NAME AND ADDRESS
Vaccination and Surveillance Record
ILARL-RESURRECTION
Print Date: 01/31/24 10:13 AM 7447 W. Talcott Ave., Suite 242
CHICAGO,IL 60631
Service /
Charting Form Performed By Type Result Provider / Clinic
Complete Date
TOXICOLOGY SCREENING URINE Negative 10/05/23 Zerina J RN
Visual Acuity Surveillance
VISUAL ACUITY RECORD EHS AS PART OF THIS ENCOUNTER See Documentation 10/05/23 Zerina J RN
ISHIHARA COLOR VISION TEST SHORT METHOD Pass 10/05/23 Zerina Jusic RN
When the Vaccination and Surveillance Report is given to the patient, sharing this information is at the patient's sole discretion.
