Immunization Coordinator, Box 35 University of South Carolina Aiken 471 University Parkway

THISFORMMUSTBE IN ENGLISH AND RETURNED BEFOREORIENTATIONTO: State SSN/StudentID# ZipCode Email DateofBirth // MoDayYr Age at time entering University BBB SEX: M ____ F ____ Applyingfor:☐Fall☐Spring☐SummerI☐SummerII☐MaymesterYear Checkone:☐Undergraduate☐Graduate☐Other Middle MoDayYr Middle ☐Dose 2 give at least 28 days after the first dose….....................................................#2// MoDayYr M.M.R.(Measles,Mumps,Rubella)[Twodosesrequiredforstudentsbornin1957orlater] a.☐ Dose1givenatage12monthsorlater………………….……..……………………......#1// RequiredImmunizationsForALLStudentsMustBeCompleted&SignedByYourHealthcareProvider (or attach a legible photocopy verified by a doctor’s signature or stamp or by a clinic or health department stamp) First City Telephone() First Name Last Address Street/P.O.Box ImmunizationCoordinator,Box35 UniversityofSouthCarolinaAiken 471UniversityParkway Aiken,SC29801 Ph:(803)641-3487,Fax:(803)641-3727 TOBECOMPLETEDBYSTUDENT Last StudentName OR b.☐ Laboratory/serologic evidence of immunity (attach a copy of a positive titer with the date of the titer) c.☐ Exemption:Iwasbornbefore1957,andthereforeamexemptfromthisrequirement ReviewFactsonMeningococcalDisease(seepage2)beforemakingadecisiononreceivingtheMenactraImmunization/Vaccine (Menactramustbedatedafter2005) a.☐ Option1:I received Menactra (MCV4) Vaccine at my healthcare provider’s office (pediatrician’s office, health department, or clinic). *BottomSection(HealthCareProvider)MustBeCompleted&Signedbyyourvaccineprovider;ORALegalPhotocopyofyourStudent’sImmunization/ Vaccine Records may be attached as long as it is verified with a doctor’s signature or stamp, or by a clinic or health department’s stamp. AdministrationDate// Menactra(MCV4)VaccineLot# MoDayYr b.☐ Option2:IwouldliketoreceiveMenactra(MCV4)VaccineintheUSCAStudentHealthCenterduringFreshmanOrientation. Pleaseprovideaphonenumber&emailwhereyoucanbestbereached:Ph( ) Email SSN/StudentNumber RequiredImmunizationsForFreshmanStudentsLivinginHousing c.☐ Option3:Ihavereadtheinformationprovidedonpage2&educatedmyselfontherisksofMeningococcalDisease. IchooseNOTtobevaccinatedwithMenactra(MCV4). Signature(parentsignsifstudentisunder18yearsofage) Date: *HealthCareProviderSignatureorStampRequiredfromallstudentsreceivingMMRandthoseinhousingreceivingMenactra Name: _______Date: Address: ) Signature: (PleasePrint) Street/P.O.Box Phone:( City State ZipCode See reverse side for additional immunization required for international students and recommended immunizations for all students Revised7/10 **AdditionalImmunizationRequiredforInternationalStudents** TuberculosisScreening 1.HaveyoueverhadapositiveTBskintest?..................................................YES________NO________ 2.HaveyoueverhadclosecontactwithanyonewhowassickwithTB?.........YES________NO________ 3.HaveyoueverbeenvaccinatedwithBCG?..................................................YES________NO________ 4.Areyouareamemberofahigh-riskgroup¹?................................................YES________NO________ 5.IfNo(to#4),youarenotrequiredtohaveaTBscreening.IfYES,youarerequiredtohaveaTBscreening. BCGvaccineisnotacceptabletomeetthisrequirement. 1.TuberculinSkinTest: DateGiven:/ / MoDayYr Result: Positive DateRead:/ / MoDayYr mm(Recordactualmmofinduration,transversediameter;ifnoinduration,write“0”) Negative (Interpretation,basedonmmofindurationaswellasriskfactors) 2.ChestX-ray(requirediftuberculinskintestispositive) Dateofchestx-ray/ / Normal _______Abnormal MoDayYr ChestX-rayFindings(ifabnormal)____________________________________________ ¹Categoriesofhighriskstudentsincludethosestudentswhohavearrivedwithinthepast5yearsfromcountrieswhereTBisendemic.ItiseasiertoidentifycountriesoflowratherthanhighTBprevalence.Therefore,studentsshouldundergo TBscreeningiftheyhavearrivedfromcountriesEXCEPTthoseonthefollowinglist:Canada,Jamaica,SaintKittsandNevis,SaintLucia,USAVirginIslands(USA),Belgium,Denmark,Finland,France,Germany,Greece,Iceland,Ireland,Italy, Liechtenstein,Luxembourg,Malta,Monaco,Netherlands,Norway,SanMarino,Sweden,Switzerland,UnitedKingdom,AmericanSamoa,AustraliaorNewZealand. RecommendedImmunizationsforAllStudents Althoughtheyarenotyetrequired,meningococcalandhepatitisBvaccinationsarestronglyrecommendedbasedon recommendationsfromtheCentersforDiseaseControl(CDC)andtheAmericanCollegeHealthAssociation.Theserecommendations aremadebasedonrecentstudiesshowingthatcollegestudents,particularlyfreshmenlivinginresidencehalls,haveasix-times greaterriskformeningitisandanincreasedriskofhepatitisBthanthegeneralpopulation. Meningococcaldiseaseisararebutpotentiallyfatalbacterialinfectionthatoccursinoneoftwoforms,eitherasmeningococcal Meningitis (a bacterial infection that causes inflammation of the brain and spinal cord) or meningococcemia (a bacterial infection of the blood). Meningitis is difficult to diagnose because of its flu-like symptoms. It progresses very quickly and may result in permanent disability or death within a matter of hours of the first symptoms. Transmission of the disease occurs from person to person through respiratoryororalsecretions.Casesofmeningitisamongteensandyoungadults15to24yearsofagehavemorethandoubledsince 1991.AskabouttheMenactravaccineforprotectionagainstMeningitis&Meningococcemia. HepatitisBvirus(HBV)exposurecanresultinaseriousdiseasethatattackstheliver.Thereisnocureforthisdisease.TheCDC estimatesthatsome80,000newcasesoccurintheUSeachyearandapproximately500peoplediefromchronicliverproblems relatedtohepatitisdiseaseannually.HBVisablood-bornediseaseandiscommonlyspreadbycontactwithinfectedblood,needlesor othersharps,orbyhavingsexwithaninfectedperson.ThebestprotectionagainstHBVisimmunization. Inaddition,itisrecommendedthatstudentsreceivetwovaricella(chickenpox)vaccinesiftheyhaveneverhadchickenpoxorreceive asecondvaricellavaccineiftheyhaveonlyreceivedonepreviously.Itisalsorecommendedthatfemalestudentsreceivetheseriesof threeGardasilvaccinestoprotectthemfromcervicalcancer. For more detailed information, visit the Centers for Disease Control & Prevention web site at www.cdc.gov or the American College Health Association website at www.acha.org. Consult with your family physician, local Health Department and your Student Health Center for vaccine information. Revised7/10

Immunization Coordinator, Box 35 University of South Carolina Aiken 471 University Parkway

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