KIRKWOOD COMMUNITY COLLEGE IMMUNIZATION RECORD
NAME_________________________
K# _________ __ DOB___________ Program_____________
Immunization requirements: In order for this form to be accepted EACH vaccination that is documented must have
a provider’s signature or stamp with the phone number of the clinic. Lab values of titres must be attached in order for
the titres to be accepted.
Vaccine
Date of
Administration
********
Clinic and Phone Number Where
Administered
Invalid without Clinic Information
**********************
Signature or Stamp of Provider
for each vaccine:
Invalid without signature or stamp
*************************
*Hep B #1
Required before clinical
experiences
*Hep B #2
*Hep B #3
Measles #1
Measles #2
Not required if born prior to 1957
Mumps #1
Mumps #2
Not required if born prior to 1957
Rubella #1
Td- One booster in last 10 years.
Tdap- One time dose required
regardless of the interval between
the last Td/Tetanus.
Varicella #1
if no documentation of chickenpox
disease
Varicella #2
if no documentation of chickenpox
disease
Seasonal Influenza
Fall/Winter only
PROOF OF TB TESTING
The following are also required:
Initial 2-Step Mantoux (TB) test (Two separate TB test placed 1-3 weeks apart and read within 48-72 hours after each TB test). The 2nd TB
test should only be done if the first TB test is negative and placed no earlier than 7 days after the 1 st TB test is read. As long as the 2nd TB
test is placed within a year of the first that will meet the standard for a 2 nd TB in a 2 step TB test.
T-Spot and Quantiferon Gold blood tests will be accepted in place of the TB skin test if the result is negative.
Test
Date Placed
Signature of Provider:
*Invalid without signature*
RT or LT
arm
Intradermally
Clinic and Phone Number
Where Administered
************
Date Read
Results
Signature of Provider:
*Invalid without signature*
2-Step:
Test #1
mm
2-Step:
Test #2
mm
Annual
Test
If longer than 12
months since test
#2 above.
mm
KDP 03/28/13
Clinic and Phone
Number Where Read
*************