IMMUNIZATION REQUIREMENTS
You must attach supporting documentation of all vaccines or titer results. Do not attach original records. Submit
photocopies only. Records can not be returned. All immunizations listed below must be current prior to starting rotation
electives.
VISITOR’S PERSONAL INFORMATION
Visitor’s Name: DOB:
Marital status: Single Married Divorced Widowed Gender: M F
IMMUNIZATION INFORMATION
Hepatitis B – Doses one and two given four weeks apart. The third dose should be at least 4 to 6 months after the first dose.
Date of Vaccine #1: Date of Vaccine #2: Date of Vaccine #3:
Date of Antibody Titer: Results of Antibody Titer: Positive Negative
Measles – One of the following is required:
1. Signed physician’s record documenting two immunizations at least 30 days apart
Date of vaccine #1: Date of vaccine #2:
2. Laboratory report of positive immune serum antibody titer Date of Antibody Titer:
Mumps – One of the following is required
1. Signed physician’s record documenting immunization Date of vaccine:
2. Laboratory report of positive immune serum antibody titer Date of Antibody Titer:
Rubella – One of the following is required
1. Signed physician’s record documenting immunization Date of vaccine:
2. Laboratory report of positive immune serum antibody titer Date of Antibody titer:
Chicken Pox (Varicella) – One of the following required
1. Laboratory report of a positive immune serum antibody titer Date of Antibody Titer:
2. Signed physician’s record documenting two immunizations at least one month apart
Date of Vaccine #1: Date of Vaccine #2:
3. History of Disease:
Tuberculosis–PPD skin test (5tu) within 11 months of program start date. This includes people who received BCG in the
past.
Date of skin test: Results at 48-72 hours: Positive Negative ______ mm
in duration
Chest X-ray taken? Yes No Results of chest x-ray Normal Abnormal *
Did you take INH / Anti Tuberculosis Treatment? Yes No
* If Chest X-Ray is abnormal please attach report
Hepatitis A (Optional)
Date of Vaccine #1: Date of Vaccine #2:
Meningococcal (Optional)
Date of Vaccine:
Tetanus – Diphtheria: Booster shot within the past ten years (Optional)
Date of Tetanus -
Diphtheria Booster:
FORM COMPLETED BY:
Name of Physician: Licensure Number:
Signature: Date:
