UC Davis School of Medicine Health Requirements
All medical students must have the following immunization and infectious disease/immunity
screening performed before attendance at UCD SOM. This form must be completed by your
health care provider. Please note: Vaccination records/labs alone are NOT sufficient.
STUDENT NAME (Please print): _________________________________ 1. Proof of Immunity ‐ Please enter DATES for the following:
Positive Measles Titer: _____________ MMR/Measles Vaccines: OR #1: _____________ #2: ______________ Positive Mumps Titer: _____________ OR MMR/Mumps Vaccines: #1: _____________ #2: _____________ Positive Rubella Titer: _____________ OR MMR/Rubella Vaccines: #1: _____________ #2: _____________ Positive Varicella Titer: _____________ OR Varicella (Chicken Pox) Vaccines: #1: _____________ #2: ____________ Positive Hepatitis B Titer: ___________ Hepatitis B Vaccines: #1: __________ #2: ___________ #3: _________ Note: Hepatitis B REQUIRES a positive titer. The vaccination series alone are NOT sufficient. T‐Dap Vaccination: #1: ____________________ Tuberculosis: Please list the result of your last tuberculin skin test (PPD). Note: The tests are annual. Date: _____________ Result: __________mm induration positive negative Chest X‐Ray: In case of a positive PPD skin test result, chest X‐ray is performed demonstrating absence of active disease. Date: _____________ Result: ____________ Institution: _____________________________________ INH: If you have taken INH, give dates: from _________ to __________ Institution: _________________ I verify that the above information is accurate and true. (Please provide facility stamp below) Name/Title: _____________________________ Signature: _______________________________ License #: _______________________________ Place State/Country: ___________________________ Facility Stamp Phone#: ________________________________ E‐mail Address: ___________________________ Here Date: ___________________________________ For specific instructions please see “Incoming_Student_Health_Requirement_Factsheet2015”:
http://www.ucdmc.ucdavis.edu/mdprogram/registrar/classinfo.html