Trinity Washington University
125 Michigan Ave. NE Washington, DC 20017
202-884-9615
Health and Wellness Center
Immunization Record
This for must be completed by your health care provider in order to register for classes
REQUEST FOR MEDICAL OR RELIGIOUS EXEMPTION
Religious exemption is allowed if the responsible person objects in good faith and in writing that the
immunization violates her religious or ethical beliefs. Medical exemption is allowed if a physician or health
care provider deems an immunization medically inadvisable. Students who wish to be exempt due to religious
or medical reasons must submit a letter from a medical provider or religious clergy which states the need for
exemption.
All students, regardless of age, are screened for Tuberculosis (TB) by a risk assessment questionnaire, consistent with
guidelines from the Center for Disease Control and the American College Health Association. Not all students will require
TB testing. Health Profession students must submit immunization information and TB test results. In addition, students
under age 26 years at time of registration are required by D.C. Law 3-20 to provide documentation of vaccination or
immunity (lab test, if appropriate) from Diphtheria, Tetanus, Hepatitis B, Measles, Mumps, Rubella and Varicella.
Students under 18 years must be vaccinated against polio.
Required Immunizations
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Three (3) doses of DPT in childhood and a booster of Tetanus/Diphtheria (TD) within the last 10 years.
Two (2) doses of measles/mumps/rubella (MMR) after 12 months of age, at least 1 month apart
Hepatitis B (3 doses)
Meningitis Vaccine
Varicella Dose 1 and 2 or a History of Chicken Pox
Three (3) doses of polio vaccine
Recommended Immunizations
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Hepatitis A
PPD (TB skin test)
Human Papilloma Virus (HPV)
Please have the health care provider complete and sign the reverse side of this form and return to:
Trinity Washington University
Health and Wellness Center
125 Michigan Ave NE
Washington, DC 20017
Fax: 202-844-9614
Email: healthcenter@trinitydc.edu
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Trinity Washington University
Health and Wellness Center
125 Michigan Ave NE Washington, DC 20017
Phone: 202-884-9615 Fax: 202-884-9614
2014-2015 Mandatory Immunization Form
To be completed by the Trinity Washington University Student
Name:
Date of Birth:
Cell Phone Number:
Email Address:
Semester and Year of Entry:
TO BE COMPLETED BY A HEALTH CARE PROFESSIONAL
A copy of an immunization record is acceptable
Tetanus/Diphtheria _____/_____/_________ (Booster in the last 10 years) OR
Tetanus/Diphtheria/Pertussis ______/________/_______ (Booster in the last 10 years)
MMR#1 ___/____/____ (Must be after 12 months of age) MMR#2 ____/_____/____ (Given at least 30 days after Dose 1
Immunizations that do not follow the above schedule must be accompanied by a lab report showing positive immunity. _____
Hepatitis B #1 ___/___/____ Hepatitis B #2 ___/___/___ (Given at least 30 days after Dose 1)
Hepatitis B #3 ___/___/___ (Given 4 months after Dose 2)
Or Attached lab report showing positive immunity _______
Varicella # 1 ___/___/___ Varicella #2 ___/___/___ (given at least 30 days after the Dose 1)
Or Attached lab report showing positive immunity ________
Polio #1 ___/___/___ Polio #2 ___/___/___ Polio #3 ___/___/___
Or Attached lab report showing positive immunity ________
For students living on campus: Meningococcal ___/___/___
Or Attached Meningitis Waiver. Can be found on the Forms section of the Health and Wellness Center website.
You will need TB testing (PPD or QFT or T-SPOT) regardless of BCG vaccination, if you meet any of the following
conditions:
1. You are a health professions student.
2. You have signs or symptoms of active tuberculosis as determined by your healthcare provider.
3. You have a chronic medical condition such as diabetes, renal failure, HIV infection, leukemia or lymphoma or other serious
condition as determined by your healthcare provider.
4. You were born in, lived in or traveled for more than 6 weeks in any country not on this list: USA, Albania, American
Samoa, Andorra, Antigua, Barbuda, Australia, Austria, Barbados, Belgium, Bermuda, Virgin Islands (British and US),
Canada, Cayman, Chile, Cook Islands, Costa Rica, Cuba, Cyprus, Czech Republic, Denmark, Dominica, Finland, France,
Gaza Strip, Germany, Greece, Grenada, Hungary, Iceland, Ireland, Israel, Italy, Jamaica, Jordan, Lebanon, Luxembourg,
Malta, Monaco, Montserrat, Netherlands and Antilles, New Zealand, Norway, Oman, Puerto Rico, St. Kitts and Nevis, St.
Lucia, Samoa, San Marino, Saudi Arabia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Trinidad and Tobago, UAE, UK,
West Bank.
5. You have worked or resided in settings such as nursing homes, homeless shelters, long-term hospital residential facilities,
prisons, or have injected drugs in the past.
6. You have had close contact with someone with infectious tuberculosis
I do not meet any of the conditions 1 through 6 above and do not require further TB testing.
Name: ____________________________ Signature: _________________________________ Date: ____________
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CONTINUED ON NEXT PAGE
A PPD-Mantoux or QFT or T-SPOT testing must be done within the past 12 months.
PPD placed _______ PPD read ________ Result in mm induration ______ Result: Positive ____ Negative____
QFT or T-SPOT: ______/______/______ Result Positive ____ Negative____ Other _____
In case of a positive PPD or QFT or T-SPOT a chest X-ray is also required. Date of X-ray _______ Result ______________
OR
Previous history of a positive PPD, QFT, T-SPOT test: Previous test __________ X-ray __________________
A normal chest X-ray within 12 months is required, unless history of INH therapy is documented.
Date of INH treatment ______________.
Signature of Healthcare Provider Required:
Printed Name: _______________________________________________ Phone: ______________________________
Signature: ____________________________ ______________________ Date: _______________________________
FOR STUDENTS UNDER 18 YEARS OF AGE
Parental permission or consent of legal guardian is needed to provide medical or surgical care to minors. The following
statement should be signed by parents or guardians of students under 18 years of age to avoid delays in treatment in the event
of an illness or accident:
I hereby authorize the staff of Trinity Washington University Health and Wellness Center to interview, assess, test and if
necessary treat my son or daughter as deemed advisable.
Signature: ____________________________________ Date: _____________________
__________________________________________________________________________________________________
Healthcare Provider Signature/Title
Date
Office Stamp
An office stamp must be used to validate this form
__________________________________________________________________________________________________
For office use only: Staff verification: ___________
Compliant
or Non-compliant
Date:____________
Noncompliant: TD/TDap
MMR
Hep B
Varicella
Meningococcal
Polio
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