Please complete and email to: regarcia@udel.edu
IMMUNIZATION DOCUMENTATION
ALL OF THE FOLLOWING INFORMATION MUST BE COMPLETED AND SIGNED BY YOUR
HEALTH CARE PRACTITIONER.
Student Name_______________________________________________________________
Last
First
Middle
Date of Birth______________________________________________
Month
Day
Year
Country of Birth_____________________________________
1. REQUIRED - ALL STUDENTS
MMR (Measles, Mumps, Rubella) Vaccine (One dose required after 12 months of age.)
MMR Vaccine Date:
_____/_____/_____, or
Month Date Year
Measles Vaccine Date:
_____/_____/_____
Month Date Year
Mumps Vaccine Date:
_____/_____/_____
Month Date Year
Rubella Vaccine Date:
_____/_____/_____
Month Date Year
2. TUBERCULOSIS (TB) RISK QUESTIONNAIRE (please circle the appropriate response)
1. Have you ever had a positive tuberculosis skin test or blood test in the past?
Response: Yes No
2. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)?
Response: Yes No
3. Have you ever had changes on a prior chest x-ray suggesting inactive or past TB disease?
Response: Yes No
4. Do you have a medical condition associated with increased risk of progressing to TB disease if infected such as
diabetes, chronic renal failure, leukemias or lymphomas, low body weight, HIV/AIDS, gastrectomy or intestinal
by-pass, chronic malabsorption syndromes, prolonged corticosteroid therapy (e.g. prednisone >15mg/day for > 1
month), other immunosuppressive disorders, or are you an organ transplant recipient?
Response: Yes No
5. Have you been a volunteer, employee or resident in a high-risk congregate setting such as a prison, nursing home,
hospital, homeless shelter, residential facility or other health care facility in the past 12 months?
Response: Yes No
6. Do you have a history of illicit drug use?
Response: Yes No
2B - If you have received TB tests or are currently taking tuberculosis medicine, please have your health care
practitioner complete the relevant information below. If you have not taken either Mantoux tuberculin skin
test (TST) or Interferon Gamma Release Assay (IGRA), or a TB blood test or a chest X-ray reading for
tuberculosis 6 months prior to arrival at the University of Delaware, you will be required to take a TB skin
test upon your arrival at the University of Delaware
TB SKIN TEST:
Date Administered:
Date Read:
_____/_____/_____
Month Date Year
_____/_____/_____
Month Date Year
Interpretation (circle one): Negative
Positive
TB Blood Test:
Quantiferon
yes
Other (please specify):
____________________________
Date:
_____/_____/_____
Month Date Year
Result (circle one):
Negative
Chest X-Ray
Chest X-Ray Date:
Result:
no
Positive
_____/_____/_____
Month Date Year
Normal
Abnormal
MEDICATION TREATMENT FOR TUBERCULOSIS:
Drug: ____________________________
Dose and Frequency: ___________________
Treatment:
Start Date:
End Date:
_____/_____/_____
Month Date Year
_____/_____/_____
Month Date Year
Health Care Practitioner Signature (Physician, Nurse Practitioner, P.A., Nurse)
Name:
_____________________________________________________
(Print Clearly)
Address:
_____________________________________________________
Signature:
_____________________________________________________
Date:
_____________________________________________________
Phone:
_____________________________________________________