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: _____________
(Date)
OR
MMR/Measles Vaccines:
#1: _____________ #2: ______________
(Date)
(Date)
Positive Mumps Titer: _____________
(Date)
OR
MMR/Mumps Vaccines:
#1: _____________ #2: _____________
(Date)
(Date)
Positive Rubella Titer: _____________
(Date)
OR
MMR/Rubella Vaccines:
#1: _____________ #2: _____________
(Date)
(Date)
Positive Varicella Titer: _____________
(Date)
OR
Varicella (Chicken Pox) Vaccines:
#1: _____________ #2: ____________
(Date)
(Date)
Positive Hepatitis B Titer: ___________
(Date)
_________
(Value)
Hepatitis B Vaccines:
#1: __________ #2: ___________ #3: _________
(Date)
(Date)
(Date)
(see Note)
Note: The vaccination series ALONE is not sufficient for Hep B. A Positive Hep B Titer (value & date) is sufficient
T-Dap Vaccination Date: #1: ____________________
Tuberculosis: Please list the result of your last tuberculin skin test (PPD). Note: The tests are annual. Your last test
date must be after August 10, 2011.
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 #: _______________________________
State/Country: ___________________________
Phone#: ________________________________
E-mail Address: ___________________________
Date: ___________________________________
For specific instructions please see “Incoming Student Health Requirement Factsheet 2016”:
http://www.ucdmc.ucdavis.edu/mdprogram/registrar/classinfo.html
Place
Facility Stamp
Here