Rose-Hulman Institute of Technology Health Services
5500 Wabash Ave. Terre Haute, IN 47803
PHONE 812-877-8367 FAX 812-872-6225 EMAIL healthservices@rose-hulman.edu
IMMUNIZATION & SCREENING FORM
NAME ___________________________________________________________ Date of Birth ____/____/____ (mm/dd/yyyy)
*MANDATORY TUBERCULOSIS SCREENING*
Tuberculosis Screening with PPD or IGRA (Blood
Test) (within the past 12 months) For ALL new
students
*NOTE-International Students – TB Screening
must be performed AFTER arrival in the US (in
compliance with State and Federal Law)
PPD
Date Applied: ____/____/_____ (mm/dd/yyyy)
Date Read: ____/____/_____ (mm/dd/yyyy)
Result in mm: ________
neg / pos
(please circle)
(Interpretation based on mm reading)
Initial of recorder _____
Chest XRAY (required only if skin
test is positive)
Date: ___/___/___ (mm/dd/yyyy)
Positive ____ Negative ____
LTB (latent TB treatment if
applicable)
Date of treatment completion:
___/___/____ (mm/dd/yyyy)
OR
IGRA (Blood Test)
Date: ___/___/_____ (mm/dd/yyyy)
Result: _____________________
Initials of records _____
BCG Date: ___/___/____ (mm/yyyy)
MANDATORY IMMUNIZATIONS
MMR (Measles, Mumps, Rubella) – 2 Doses Required
1. On or after first birthday ___/___/____ (mm/dd/yyyy)
2. At least 4 weeks after #1 dose__/___/___ (mm/dd/yyyy)
Tetanus/Diphtheria or Tetanus/Toxoid Immunity
Booster dose of Td/Tdap with last 10 years
___/___/____ (mm/dd/yyyy)
Polio Immunity
Date Polio Series Completed ___/___/____ (mm/dd/yyyy)
Meningococcal Vaccine
1. ___/___/____ (mm/dd/yyyy
2. ___/___/____ (mm/dd/yyyy)
(second dose to be within 5 years after first dose)
RECOMMENDED VACCINATIONS
Hepatitis B Series
1. ___/___/___ (mm/dd/yyyy)
2. ___/___/___ (mm/dd/yyyy)
3. ___/___/___ (mm/dd/yyyy)
Hepatitis A Series
1. ___/___/___ (mm/dd/yyyy)
2. ___/___/___ (mm/dd/yyyy)
3. ___/___/___ (mm/dd/yyyy)
Varicella Vaccine
1. ___/___/___ (mm/dd/yyyy)
2. ___/___/___ (mm/dd/yyyy)
3. _______ History of Disease
Human Papillomavirus (HPV)
1. ___/___/___ (mm/dd/yyyy)
2. ___/___/___ (mm/dd/yyyy)
3. ___/___/___ (mm/dd/yyyy)
HEALTH CARE PROVIDER
______________________________________ Address ____________________________________________________
(print provider name)
Provider Signature ____________________ Date________
Phone (___)_______________ Fax (___)______________