STUDENT HEALTH SERVICES IMMUNIZATION FORM Name: _________________________________________ Date of Birth: _________________Phone Number: _______________________ Enrolled School: ________________________________ Program if applicable: _________________________________________ (Medical, Graduate, or Health Professions) (For example: Physician Assistant, Clinical Psychology, etc.) Required Immunizations\Vaccinations Date(s) (1). Tetanus/Diphtheria/Pertussis (Tdap) #1____/____/____ (Note: Td, DPT or Dtap does not satisfy this requirement.) (2). MMR Immunization(s) #1____/____/____ #2 ____/____/____ (3). Measles (Rubeola) #1____/____/____ #2 ____/____/____ OR Measles (Rubeola) Immune Titer ____/____/____ (Note: A copy of your positive immune titer must be submitted.) (4). Mumps #1____/____/____ OR Mumps Immune Titer ____/____/____ (Note: A copy of your positive immune titer must be submitted.) (5). Rubella #1____/____/____ OR Rubella Immune Titer ____/____/____ (Note: A copy of your positive immune titer must be submitted.) (6). Hepatitis B #1____/____/____ #2 ____/____/____ #3____/____/____ (Note: This is a three part series with doses given at zero, one and six months.) OR Quantitative Hepatitis B Immune Titer ____/____/____ (Note: A copy of your positive immune titer must be submitted.) (7). Varicella (Chicken Pox) Immunization #1____/____/____ #2 ____/____/____ (Note: Proof of disease not accepted.) OR Varicella (Chicken Pox) Immune Titer ____/____/_____ (Note: A copy of your positive immune titer must be submitted.) (8). Meningitis (if under age 22) #1____/____/____ (Note: Meningitis Vaccination must have been given within 5 years of your start date and a minimum of 10 days before the start of your classes.) (9). Tuberculosis Screening: Negative Quantiferon or T-­‐Spot Blood Test (within past six months) Date___/___/___ Results _________ (copy of report must be submitted.) OR Negative Tuberculin skin test (ppd) (Note: PPD’s should be placed within 6 months of starting your UTSW program) Date Placed: ____/____/____ Date Read: ____/____/_____ Results: _______________ millimeters of induration: ______ Positive Tuberculin skin test (ppd) or history Date ____/____/____ millimeters of induration: _______ Positive Quantiferon or T-­‐Spot Date _____/_____/______ (Note: For positive PPD’s and Quantiferon/T-Spot test, it is required that you submit a copy of your chest x-ray radiology report.)
Chest x-­‐ray results Date ____/____/____ Results: ___________________
Did you take INH prophylaxis? YES NO Start Date ____/____/____ End Date ____/____/____ Declined INH on ____/____/____ Health Care Provider – I verify that this information is true. Date: ______________ Name (printed): _____________________________ _____________Signature: ___________________________________________ Address: _______________________________City: ______________________State: __________ Zip _______________ 5323 Harry Hines Blvd./ Dallas, Texas 75390-­‐8861 / (214) 645-­‐8690 Phone Number: _________________________________ Fax Number: _____________________________ 5323 Harry Hines Blvd./ Dallas, Texas 75390-­‐8861 / (214) 645-­‐8690