Faculty Immunization Form
GENERAL STUDENT INFORMATION (REQUIRED BY ALL FACULTIES)
To Examining Health Practitioner: The University of Alberta requires that all students attending a health science faculty
present this completed third party immunization clearance form prior to formally commencing their program. Completion of
faculty immunization requirements is the responsibility of the students. Copies of previously completed immunization records
may be attached to this form if appropriate. Refer to attached U of A Immunization Guidelines.
Full Name: _________________________________________________________________________
Address: _________________________________________________________________________________________________________
Faculty/Dept Stream: ___________________________________________ Country of Birth: ________________________
Student ID: (if available): _______________________________________ Date of Birth:_______________________________
Latex Sensitivity/Allergy?
YES  NO 
If yes, please clearly explain the work restrictions: _____________________________________
A. IMMUNIZATION RECORD
Vaccine
Requirements
Primary series of tetanus and
diphtheria AND a reinforcing dose in
the past 10 years.
Tetanus,
Diphtheria,
Pertussis
Polio
* 1 dose of dTap ( i.e. Adacel) as an
adolescent  12 yrs, highly
recommended when booster
is due.
** 1 dose of dTap is mandatory for
Medicine & Nursing students upon
entry to program regardless of date of
last Td.
Documentation of primary series of 3
doses. Boosters not recommended
unless for travel.
Primary Series ( 3 doses)
 Yes
 No
Date of last booster ____________________________________________
Vaccine Administered: ____________________________________________
Primary Series ( 3 doses)  Yes
 No
Date of last dose: ___________________________________________________
Documentation of
Hepatitis B series.
Serological evidence of
Hepatitis B must be
provided (Anti-HBs positive).
PLEASE ATTACH RESULTS
Hepatitis B
Results
If negative antibody result, HBsAg
must be done before booster.
Dates of vaccination:
1. ________________________ 2. ________________________ 3. ________________________
Further Doses: ________________________________________________________________
Pre-entrance serology
HBsAb (Hepatitis B surface antibody)
Date: ________________________
DIETETIC INTERNS do not
qualify for free HBV vaccine.
DENTISTRY & DENTAL HYGIENE
STUDENTS require both HBsAb and
HBsAg.
Result:
pos/neg
If HBsAb is negative, check HBsAg (Hepatitis B surface antigen).
Date _________________Results:
pos/neg
If antigen positive, student needs to contact faculty for further advice re:
program restrictions.
Fac Med Form 2012
Created: 03/08/2010
Modified: 06/07/2012
Measles,
Mumps,
Rubella
Students must have documentation
showing that they have had
2 doses of Measles and Mumps and
1 dose of Rubella vaccine.
Date of 1st MMR: _______________________________________
Date of 2nd MMR: _______________________________________
Further Doses: _______________________________________
_______________________________________
If the student was born
before 1970, 1 dose of MMR
required.
If lacking documentation
vaccination is preferred to
serological testing.
Most students will require a
One Step Mantoux.
Mantoux
Testing
(TB)
Varicella
(Chickenpox)
Two-step Mantoux screening
needs to be done for the
following students:
o Proof of receiving BCG
Vaccination.
o Age is greater than or
equal to 55 years.
Only if necessary:
Rubella serology, Date: _____________________ pos/neg
Measles serology, Date: _____________________ pos/neg
Mumps serology, Date: _____________________ pos/neg
Date of skin test:
1.
Result:
2.
Result:
If the Mantoux test is positive, or they have a history of a positive Mantoux test, a
CXR within 12 months is required.
A referral to TB services needs to be made for positive Mantoux. (Referrals are
made only for those less than 35 years of age).
A 2nd Mantoux test is
administered 7-28 days after
the first for the above
situations.
Chest x-ray results: _____________________________________
Definite Hx of disease or
serological evidence of
immunity. If non- immune,
vaccination is required. 2 doses
for adults with a min. 28 days
between doses.
Hx of Disease ___________________ OR Serology ___________________
Referral to TB Services:
Yes  No
OR
Date of vaccination: _______________________________________________
Date of vaccination: ________________________________________________
Influenza
Additional
Immunization
History:
Recommended Yearly
1 dose
Date:
_______________________________________
Date: ______________________________________________
_______________________________________
Date: ______________________________________________
Physician or Nurse
Physician or Nurse
Date:
_______________________________________
___________________________________
______________________
please print name
signature
Students: Do not destroy. Please retain a copy for your records. It is your
responsibility to ensure that this form AND ALL REVISIONS to this form are forwarded
to your faculty
Fac Med Form 2012
Created: 03/08/2010
Modified: 06/07/2012