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Referral Form - Example


Columbus Public Health created a two sided referral card for their Adult High Risk Hepatitis Program. One side of the card has modifiable information about theĀ  immunization clinic including their office hours, address, and telephone number. The other side has patient information including the date, patient's name, identified risk, and employee signature.

Click here for NACCHO's Collection of Adult Hepatitis B Virus (HBV) Vaccination Tools and Resources.


Infectious Disease Prevention and Control Toolkit

Keyword Area:

Immunization, Infectious Diseases, Workforce Competency


Institutional Author:

Columbus Public Health





The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.