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1.

Background on individual representative requesting authorization.

Representative Name:

Title:

Company Name:

Address:

City, State, Zip:

Phone:

Fax:

2.

Services representative are authorized to perform:

Sales

Education

Special Procedures

Other

3.

Written proof of training/certification.  (The manufacturer must provide written proof of training to provide the services listed in Item 2 to ensure that the representative qualifies to provide these services.)

Date Provided:

4.

List of departments representative will visit:

5.

Infection Control and OSHA bloodborne pathogen training?  (Manufacturer’s responsibility)

Date Provided:

6.

Aseptic Principles and Sterile Technique?  (Manufacturer’s responsibility)

Date Provided:

7.

Department attire and traffic patterns:

Location:

Date:

Location:

Date:

Location:

Date:

8.

Department Safety Training and Tour:

Location:

Date:

Location:

Date:

Location:

Date:

9.

Current vaccination and immunization record:

Tetanus booster within the past ten years

Measles, mumps and rubella vaccination or documentation that the HCIR is immune to these conditions

Intradermal, protein-derivative-type tuberculin skin test within the past twelve months (unless the HCIR is known to have an allergic or positive reaction to such test, in which case the HCIR should under go a chest x-ray).

ENCOURAGED:

Varicella immunization or documentation that the HCIR is immune from this condition.

Hepatitis B immunization that can be documented.

10.

Approval obtained from the department director/designee and MD if applicable.

Updated 9.1.06

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