-There must be documentation of one of the following :

1 step TB Skin test

Negative Quantiferon Gold Blood Test

If the results are positive a clear Chest X-Ray is required.
Skin Test Placement Date: ____/____/____
Skin Test Read Date: ____/____/____
Results in millimeters: __________mm
If positive skin Test, please attach a copy of your Chest X-ray Report within past 2 years.
There must be documentation of a Tdap booster within the past 10 years.
Read Carefully: If you have had the Tetanus & Diphtheria only, you MUST now get the Tdap to include the Pertussis immunization!
Tetanus-Diphtheria-Pertussis
Tdap vaccine Date: ____/____/____
*CDC recommendation currently states: *Healthcare personnel should receive a single dose of Tdap if they have not previously received Tdap regardless of the time since the last Td dose.
Read Carefully: If you have had the Tetanus & Diphtheria only, you MUST now get the Tdap to include the Pertussis immunization!
-There must be documentation of the following:

2 vaccinations

Positive antibody titer (lab report required: Titer Version: VZV IgG).
Student must have serologic immunity (demonstrated by a positive antibody titer) to Varicella.
Only providing vaccination documentation will not be sufficient. Student must obtain the titer.
Varicella: Dose#1 ____/____/____ Dose#2 ____/____/____
Varicella Titer Date ____/____/____ Immune: Yes ____ No ____
***Lab Report with Quantitative results and Reference Range MUST be attached.
*Qualitative results on titers will not be accepted. You are required to produce a quantitative titer report.
Read Carefully: If you have received the 2 vaccinations for Varicella, you ARE required to provide a titer as well. If you have had Chicken Pox in the past, you are only required to provide a titer. A doctor’s note stating you had
Chicken Pox will not count. You MUST obtain the titer! If your titer comes back negative you will need to speak with your doctor about revaccination or a booster.
*If you have had the illness or an exposure, you may get the titer first. If your titer does not read positive, you must begin the vaccine sequence.
Required Titers: Varicella: VZV IgG

-There must be documentation of both:

2 vaccinations and Positive antibody titers for all 3 components (lab reports required)
MMR: Dose#1 ____/____/____ Dose#2 ____/____/____
Date of Measles Titer ____/____/____
Date of Mumps Titer ____/____/____
Immune: Yes ____ No ____
Immune: Yes ____ No ____
Date of Rubella Titer ____/____/____ Immune: Yes ____ No ____
***Lab Report with Quantitative results and Reference Range MUST be attached.
*Qualitative results on titers will not be accepted. You are required to produce a quantitative titer report.
-There must be documentation on BOTH of the following:

3 vaccinations

Positive antibody titer (lab report required Titer Version: Hepatitis B Surface antibody)
Read Carefully: You must provide proof of both the 3 vaccinations and positive antibody titer. In regards to
Hepatitis B. If your titer comes back negative you will need to begin the sequence over.
*If you have had the illness or an exposure, you may get the titer first. If your titer does not read positive, you must begin the vaccine sequence.
Student must have serologic immunity (demonstrated by a positive antibody titer) to Hepatitis B
Only providing vaccination documentation will not be sufficient. Student must obtain the titer.
Hepatitis B Vaccines: Dose#1 ____/____/____ Dose#2 ____/____/____ Dose#3 ____/____/____
Hepatitis B Antibody Titer Date: ____/____/____ Immune: Yes ____ No ____
***Lab Report with Quantitative results and Reference Range MUST be attached.
*Qualitative results on titers will not be accepted. You are required to produce a quantitative titer report.
Required Titers: Hepatitis B: Hepatitis B Surface antibody
-Must submit documentation of a flu shot administered during the current flu season. Summer Admits will not be required to hold an Influenza vaccine at admission. ALL students must obtain the Influenza vaccine once the season becomes available. (Fall Semester: Month of October)
Vaccine Administered Date: ____/____/____
-Course must be by The American Heart Association Healthcare Provider Course. Copy must be front and back.
Card must also be signed.
Healthcare Provider's Signature __________________________________________________
Healthcare Provider's Printed Name________________________________________________
Providers License Number _____________________________
Date: __________________ Office Phone # ______________________________________