IMMUNIZATION RECORD
Keep a paper or
electronic copy for
your records.
Required of all McWhorter Pharmacy Students
Immunization Status is held to the standards for healthcare professionals.
Name: _____________________________________________________________________________ SID: __ __ __ __ __ __ __ __ __
Last
First
MI
Cell Phone # ________________________________
Preferred name
Date of Birth: ____/____/________
Entering: _____ Year
MEASLES / MUMPS/ RUBELLA (MMR) All entering students born after January 1, 1957 must have A or B:
A: Documentation of two doses of MEASLES/MUMPS/RUBELLA (MMR) vaccine
 First dose administered since January 1, 1968 and on or after the first birthday
 Second dose administered at least 28 days after the first dose
B: Documentation of immunity by blood test (titer) demonstrating protective antibody levels to measles, mumps and rubella.
#1
M.M.R
(Measles,Mumps,Rubella)
#2
Date of Titer
Measles
____/_____/_____
_____/____/_____
Attach copy of report
_____/_______/______
Date of Titer
Mumps
Attach copy of report
_____/_______/______
Date of Titer
Rubella
Attach copy of report
______/______/______
HEPATITIS B
If a vaccination series has not previously been completed, the first dose must be administered prior to the first
week of class attendance. Completion of the full series is required by March 1st of the P1 year. Documentation of immunity by a
blood test (titer) is required once series is completed or in lieu of vaccinations.
#1
#2
_____/_____/_____
Date of Titer
#3
_____/_____/_____
_____/_____/_____
TETANUS DIPTHERIA PERTUSIS (Tdap)
Tdap is required ( one-time vaccination)
Attach copy
of report
Hepatitis B
Surface Antibody
_____/_____/_____
MENINGOCACCAL QUADRIVALENT
Required of all students living in University housing.
Tdap
If Tdap over 10 years ago, booster required.
Tetanus/diphtheria date:
_____/______/_______
Td
Students <21 years must have a
dose of conjugate vaccine at
> 16 years of age
_____/______/_______
___/____/___
VARICELLA (Chickenpox)
Documentation of two doses of vaccine at least 4 weeks apart. The first dose must be administered prior to the first week of class
attendance. Documentation of immunity by blood test (titer) or date of disease is acceptable in lieu of vaccine administration dates.
#1
#2
_____/_____/_______
Date of Titer
_____/_____/_______
Varicella AB,
IgG
_____/_____/______
Attach copy
of titer
report
Date of Disease
_____/_____/______
TWO-STEP TUBERCULIN SKIN TEST (Mantoux PPD) Skin tests should be 1-3 weeks apart (must be within 12 months prior to first day. )
1.
Initial Tuberculin Skin Test (TST)
nd
2 Tuberculin Skin Test (TST)
2.
Date Placed: _____/____/_____
Date Read: ____/_____/_____
Results: (mm induration) __________________
Date Placed: _____/____/_____
Date Read: ____/_____/_____
Results: (mm induration) __________________
Chest X-ray required if TST is positive OR if history of positive TST in the past. Chest X-ray must have been within 12 months prior to first day of class.
Date of Chest X-Ray: _________________
Results: (*attach copy of test results or report )
THIS RECORD MUST BE SIGNED BY A HEALTH CARE PROVIDER (Health Department stamp acceptable)
MD/PA/NP/RN Signature: _________________________________________________
Print Name: ________________________________________________
Phone: (
Date: _________________________
) _______________________________
Address: ____________________________________________________________________________________________________
RETURN ORIGINAL FORM TO:
SUBMIT COPY TO:
Samford University Health Services, 800 Lakeshore Dr., Birmingham, AL 35229
McWhorter School of Pharmacy, Ingalls 252, 800 Lakeshore Dr., Birmingham, AL 35229