Student Health Services
30 Bee Street – Suite 102
Charleston, SC 29425
Telephone 843-792-3664
Fax 843-792-2569
MUSC Student Matriculation Requirements
All MUSC students, including full-time, part-time, distance, current employees, or former students, are
required to submit the following information. The Mandatory Immunization Requirements Form must be
completed and signed or stamped by a licensed physician, NP, PA or nurse and received by Student Health
Services before students will be allowed to attend classes.
Forms listed below must be completed, signed or stamped, and
received by Student Health Services on or before the due date.
Please, maintain a photocopy of all records prior to sending.
Checklist of forms to return to Student Health Services





Immunization Forms
Hepatitis B Immunization Form
Tuberculosis Screening Form
Additional/optional Immunizations Form
Copy of Health Insurance Enrollment Confirmation or Waiver Confirmation (email from AIG)
On-line forms listed below must be completed on or before the due date.
Checklist of required information to be entered on-line
1. Go to https://lifenet.musc.edu
2. Use your MUSC netID and password to log in.
3. Go to “Forms” (left column) and complete the following sections:
 Health History
 Consent for Treatment
 Notice of Privacy Practices
 Latex Questionnaire
 Meningococcal Questionnaire
 Tuberculosis Questionnaire
 Immunizations (see instructions for entering data)
Available Prematriculation Vaccines Available at Student Health
The Hep B, Tdap, and PPD immunizations/screenings are available at Student Health Services for a fee. Please,
Contact SHS at 792-3664 for hours and fees. You do not need an appointment.
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Frequently Asked Questions
What are the most common errors students make when submitting their records?
1. Missing lab reports
2. Antibody Titers – Incomplete or missing information on lab reports
a. Lab reports must include one of the following: (see “unacceptable documentation” for additional
information)
i. Numerical values that indicate immunity OR
ii. Numerical reference range for a response of “positive”, “reactive”, or ”immune”
3. Unverified immunizations (a stamp or signature and contact information are required)
4. Verification incomplete (e.g., initials instead of complete signature or stamp)
5. Incomplete dates (e.g., month/year instead of month/day/year)
6. Verification noted with “ditto” marks is unacceptable – each immunization requires a date/signature/contact
information
7. PPD (TB test) > 12 months before your start date at MUSC (must be ≤ 12 months prior to when classes begin)
8. Tine test is not acceptable for PPD – must be Mantoux method
9. A Tdap dated prior to 6/10/2005 (Adult Tdap was not available prior to 6/10/2005) If you have had a Tdap >10
years ago, documentation of the Tdap and the booster (Td) are required.
10. Incomplete series (received one of two doses; did not complete the series)
11. Unidentifiable student information (e.g., name, DOB, email, etc. not written at the top of each page)
What is considered unacceptable documentation or proof of immunizations?
 Partial dates are not acceptable. Dates must include month, day, and year.
 Initials are not acceptable. The verification must be a signature (or stamp) and include a contact telephone
number.
 Parental signatures (even if he or she is a health care provider) are not acceptable as verification.
 Lab reports with insufficient information (Lab reports that do not include quantitative (numerical) results )
 Lab reports with qualitative results (i.e., “positive”, “reactive”, or “immune”) must indicate the numerical
reference range for these values. (e.g. the lab report specifies that “A positive value indicates the Hepatitis B
Surface Antibody is >/= 10 mIU/mL and is considered to have protective immunity.” )
 Documentation, letters, reports, etc. in a language other than English are not acceptable. All information must
be in English (or an official translation of documents in English)
When are the forms due?
 Both printed and on-line forms are due on the date specified in the email you received
 Copies of actual lab reports with titer values/indices/reference ranges must be included
 Immunization data must be entered on-line in LifeNet prior to the date specified in the email you received
Who can verify immunizations?
 The forms must be verified by a licensed healthcare professional.
May I substitute copies of other immunization records (e.g., undergraduate records) for verified records?
 No. The attached forms must be completed and verified by a licensed physician or nurse.
Where do I send my completed forms?
 Send completed forms plus lab reports and related documentation to
MUSC Student Health Services
30 Bee Street – Suite 102
MSC 980
Charleston, SC 29425
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
Forms may also be dropped off at this location during regular business hours. (Monday – Friday, 8:00 am to 4:30
pm. Student Health is closed on all State Holidays.)
What if I have personal or religious reasons for not completing a specific requirement?
 Waivers of specific requirements for personal and/or religious reasons are accepted; however, the request for a
waiver must be signed by the dean of the college and sent to Student Health Services. Contact your dean’s
office regarding a waiver.
What if I have a medical reason for not completing a specific requirement?
 If you have a medical reason for not receiving a particular immunization, please submit a written statement
from your physician indicating the adverse reaction or medical circumstances for which immunization is not
considered safe. The physician must sign and date the letter and include his/her address and telephone
number.
Who do I contact if I have questions?
 For questions regarding printed forms and immunizations, contact Student Health Services at 843-792-3664.
 For questions regarding on-line forms, contact Education and Student Life at 843-792-9835.
Does Student Health Services administer pre-matriculation requirements?
 Yes; however, you need to have received your netID and established your MUSC email account prior to receiving
any health services. SHS administers the Tdap, and Hep B vaccines. Fees apply.
Where can I go for a TB skin test?
 You can go to a local ambulatory clinic, primary care physician, travel clinic, or urgent care facility OR you can
come to MUSC Student Health Services once you have established your MUSC email account. Fees apply.
I need to have antibody titers drawn to document immunity to MMR, Varicella, and Hepatitis B.
Can I have this done at MUSC?
You have two options for having your antibody titers drawn.
1. You can have this done at the lab of your choice (your healthcare provider writes the order)
2. If you are in the area you can stop by Student Health and pick up an order form to take to one of the six local
laboratories with which Student Health Services has contracted. Prices under this contract are significantly
reduced for students. Payment is required at the time you pick up the order. Check, credit or debit cards are
accepted. Titers are required by many of the institutions where MUSC students complete clinical rotations. If
done prior to matriculation, you will not experience the inconvenience and expense of having titers done at a
later date.
 Measles, Mumps, Rubella, Varicella = $80.00
 Measles, Mumps, Rubella, Varicella, Hepatitis B = $100.00
Student Health Services will record all vaccines, TB screenings and titer results in your records administered or ordered
through Student Services.. You do not need to submit those records.
What happens if I do not submit the required documentation and information?
 The dean of your college is notified a hold is placed on your student account until you are in compliance.
Will I be notified if there is a problem with my record?
 If you are missing any information, you will be notified through your MUSC email account that you have a secure
message in LifeNet. The secure message in LifeNet will inform you of any missing documentation or
information. You are responsible for logging into LifeNet and reading all secure messages.
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Student Health Insurance - REQUIRED
REQURIED DOCUMENTATION: A copy of the email you receive from AIG
indicating your insurance plan was approved OR confirming your enrollment
1. To be completed by “Insurance Due Date” noted in the email you received.
2. To enroll or submit your information go to http://www.studentinsurance.com/Schools/SC/MUSC/?CollegeID=94
3. You will need your MUSC Student ID number. This is a 9-digit number beginning with “90”. You can find
your MUSC Student ID number on your WebAdvisor account.
All MUSC students, including full-time, part-time, distance, current employees, or former students, are
required to have health insurance. If you do not provide proof an ACA compliant plan*, you will be
automatically billed for the MUSC-sponsored Student Health Insurance Plan.
Depending on your situation, you have several options for student health insurance for summer 2014.
1.
2.
3.
4.
Parent’s / Spouse Health Insurance Plan
Employer-offered plan
MUSC Student Health Insurance Plan (AIG)
Individual Health Insurance Plan through the Marketplace Exchanges or an insurance
company/licensed agent/broker
To review the MUSC plan, visit
http://www.studentinsurance.com/Schools/source/PDFs/brochures/SC/MUSC/MUSCbro13.pdf
For additional information visit
http://academicdepartments.musc.edu/esl/studenthealth/student_resources/healthinsinfo.html
*Comparable coverage criteria

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
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
Coverage must be effective on or before January 1 (spring) or May 14 (new summer students only) or August 18 (fall) and extend through
the semester including breaks and holidays
Coverage must allow the insured student to receive services in South Carolina (note – these are requirements for all plans according to
the Patient Protection Affordable Care Act):
o Ambulatory patient services
o prescription drugs
o emergency services
o rehabilitative and habilitative services and devices
o hospitalization
o laboratory services
o maternity and newborn care
o preventive and wellness services
o mental health and substance use disorder services
o chronic disease management
including behavioral health treatment
o pediatric services including oral and vision care
Coverage amount of $100,000 per policy year per illness/accident/injury
Coverage amount of US $500,000 or greater aggregate per lifetime
No pre-existing condition limitation
A combined benefit of US $50,000 for medical evacuation and repatriation of remains (for international students)
A deductible equal to or less than $1,000
A maximum out-of-pocket limit of $6350
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Suggestions for all students
1. Read the information pages and frequently asked questions.
2. Go to the AIG website and enroll or waive out of the MUSC student health insurance plan.
3. Send (fax, email, deliver) the immunization forms to your healthcare provider.
4. Have lab work (blood draw for titers) done. (Titers ordered through and vaccines and TB screenings
administered through Student Health do not need to be submitted in your packet. SHS records those.)
5. Schedule a date and time for pickup of forms (including your lab reports) from your provider.
6. Review the forms prior to leaving the office and ensure all are completed according to instructions. (See
“common errors” on previous page)
7. Print a copy of the confirmation email you receive from AIG. This email will confirm enrollment or confirm
your request for a waiver was approved.
8. Make a photocopy of your forms for your records.
9. Enter your data on-line (https://lifenet.musc.edu) prior to sending the forms to Student Health.
10. Send or deliver original SHS forms and copies of original immunization documentation and lab reports to
MUSC Student Health.
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On-line forms listed below must be completed on or before the due date.
You will need the original or clear photocopy of the required forms in order to submit the requested
information.
Please wait to enter your Immunization Data (under “Immunizations”) until you have received your lab titer
reports and your healthcare provider has completed the required information. (You do not need to record lab
titers ordered through SHS and vaccines administered by SHS. SHS enters those directly into your record.)
You will not be able to save and return to a form in LifeNet. You can cancel a form; however, you will lose any
data which you have entered.
You will not be considered compliant without entering your immunization records on LifeNet.
To complete the on-line forms:
1. Go to https://lifenet.musc.edu
2. Use your MUSC netID and password to log in.
The message “no record found” is usually due to a difference in the date/time your netID is assigned and the date/time
when your information is entered in the Student Health Services system. If you see this message, please wait 72 hours
and attempt to log in again. If after 72 hours you are still unable to log in, please contact Student Health Services.
3. Go to “Forms” (left column) and complete the following sections (see instructions on following
pages to access forms and enter data)
 Health History
 Consent for Treatment
 Notice of Privacy Practices
 Latex Questionnaire
 Meningococcal Questionnaire
 Tuberculosis Questionnaire
 Immunizations
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Instructions for entering immunization data at https://lifenet.musc.edu
1. Using your MUSC netID and password, log in to https://lifenet.musc.edu
2. Enter your Date of Birth.
3. Click on “Forms” in the left column.
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4. Click on and complete each of the 6 forms.
5. Detailed instructions for entering immunization data:
5a. Click on “Immunizations”
5b. Read the information at the beginning of the form.
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5c. Remember, you will not be able to save and return to this form. You can cancel the
form; however, you will lose any data which you have entered.
5d. Please do not attempt to enter your Immunization Data (under “Immunizations”)
until you have received your lab titer reports and your healthcare provider has
completed the required information on pages 6 – 12.
5e. Use the information in your completed immunization packet to enter data. The
location where you need to enter data in the on-line form is found in the far-right
column.
Example: Measles Titer
The on-line immunization form
You then enter the test date and result.
If you have questions, please contact Student Health Services at 843-792-3664.
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Summary of Required Immunization Options
The summary below identifies the options for documenting compliance.
Please use the forms on the following pages for documentation and verification.
Measles,
Mumps,
Rubella
Immunity
Varicella
Immunity
Tetanus /
Diphtheria/
Pertussis
Vaccine
Option A
students born on or after 01/01/1957
Option B
Option B
for students born on or after 01/01/1957
for students born on or before 2/31/1956
Option C (Required for Accelerated BSN
students)

Documentation of 2 MMR vaccines received on or after age of 12
months and both after 12/31/1967
 Documentation of 1 MMR vaccine received after 12/31/1967
 Copy of Immune MMR IgG Antibody Titer lab (Provide lab report.)
Copy of lab report of Immune Varicella IgG Antibody Quantitative
Titer or Qualitative Titer with numerical reference range
Option A

Option B
 Documentation of two varicella vaccines (Varivax)
Option C
if titer (Option A) is negative or equivocal
 Documentation of two varicella vaccines (Varivax)
Required

Exception
 Documented Pertussis Allergy
Option A
 of immune Hepatitis B Surface Antibody Quantitative Titer or
Adult Tdap on or after 6/10/2005. If your Tdap is >10 years ago, Td
is required in addition to Tdap documentation
Documentation of hepatitis B vaccine series and a copy of lab report
Qualitative Titer with numerical reference range
Hepatitis B
Immunity
Tuberculosis
Screening
Start or repeat series (refer to Hepatitis B Immunization Form for
options)
Option B

For students in MHA/DHA program or
College of Graduate Studies
 Not required
Option A

Option B
 Blood Test ( (QuantiFERON-TB Gold or T-spot)
Option C – previous positive TB test
Two Intradermal PPD (Mantoux 5TU) >7 days apart and within 3
months of your MUSC start date (Tuberculosis Skin Tests)
1)Documentation of the positive TB test (TB skin test or blood test)
If no documentation of TB skin test, blood test required.
2) Check X-ray report – taken after positive TB test
3) Dates of TB prophylactic treatment
Option A
 Proof of vaccination
Option B
 Waive out (see Forms in section above)
Meningococcal
Vaccine
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All pages from this point forward are
to be completed and submitted to
Student Health Services by the due
date noted in the email you
received.
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Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
________________ / ____________
Confirmation of Health Insurance Requirement
Waive Student Health Insurance Plan
 I submitted my waiver request to AIG on _____ / _____ / _____
 I received an email indicating my waiver request was pending _____ / _____ / _____
 I received an approved waiver on _____ / _____ / _____
Note: If additional information is requested, please send to AIG. Pending requests are not
considered approved.
Enroll in Student Health Insurance Plan
 I enrolled on the AIG website on _____ / _____ / _____
 I enrolled successfully and received a confirmation email on _____ / _____ / _____
My confirmation number is M _________________________
INSERT COPY OF EMAIL CONFIRMATION
OF APPROVED WAIVER OR SUCCESSFUL ENROLLMENT
Behind this page
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Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
________________ / ____________
Rubeola (Measles), Mumps, Rubella and Varicella
Proof of immunity to Measles (Rubeola), Mumps, Rubella and Varicella can be provided by either :
Option A (MMR) -Documentation of two doses of MMR vaccine.
Option A (Varicella) -Documentation of two doses of Varicella vaccine.
OR
Options B (MMR )-Copies of positive lab titers results demonstrating positive immunity for MMR
Options B (Varicella)-Copies of positive lab titers results demonstrating positive immunity for Varicella
Below, you have a choice to provide documented proof of your immunizations or attach copies of your titer results. Lab
reports must indicate whether the antibody results are in immune range. Lab reports with quantitative (numerical)
results must include that lab’s numerical reference range for immunity (eg >10mIU/ml=immunity.) Lab reports with
qualitative results (“positive”, “reactive”, etc.) must indicate whether or not the numerical reference range for these
values is immune. Documented proof of vaccines is REQUIRED if antibody titers are equivocal /borderline or negative.
Option A. Two MMR – First MMR must be given after 12 months of age.
(For students born on or after 01/01/1957)
Two Varicella Vaccines
Option B. Titers (Required for Accelerated BSN students.)
Complete titers for Measles, Mumps, Rubella and/or Varicella titers.
Attached copies of your titer lab results demonstrating immunity.
Enter the data in https://lifenet.musc.edu as described on page 9 (5e).
Documented proof of vaccines are REQUIRED if titer results are equivocal/borderline or negative
MMR Vaccine
Month/Day/Year
Of Vaccine
Signature (or stamp) of healthcare
professional
Print Name of Healthcare Professional
Address of healthcare
professional/facility
Dose #1
Dose #2
____ / ____/ ____
____ / ____/ ____
#5 Measles,
Mumps, Rubella
Immunizations
(First does must be
given after 12
months of age.)
Leave blank if not
applicable. (i.e.
submitting immune
titer results)
Telephone of healthcare
professional/facility
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Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
________________ / ___________
MMR AND VARICELLA TITERS ARE REQUIRED FOR ACCELERATED BSN STUDENTS
College/Program
Measles, Mumps, Rubella, Varicella Titers
Antibody Titers
Measles IgG Titer
Month/Day/Year
Of Titer
____ / ____/ ____
Titer Results
(Check appropriate box)
After you receive lab reports (if
applicable) and the remaining
forms have been completed by
a healthcare professional, then
enter these data on-line at
https://lifenet.musc.edu
#1 Measles IgG Titer
 Positive/Immune Titer Value ____________
 Equivocal/Borderline/Negative Titer Value ____________
(REQUIRES DOCUMENTATION OF TWO VACCINES – refer to page 2)
Additional requirement
Attach copy of lab report (mail to SHS with all Immunization Forms)
Antibody Titers
Mumps IgG Titer
Month/Day/Year
Of Titer
____ / ____/ ____
Titer Results
(Check appropriate box)
 Positive/Immune Titer Value ____________
 Equivocal/Borderline/Negative Titer Value ____________
(REQUIRES DOCUMENTATION OF TWO VACCINES – refer to page 2)
Attach copy of lab report (mail to SHS with all Immunization Forms)
Antibody Titers
Rubella IgG Titer
Month/Day/Year
Of Titer
____ / ____/ ____
 Positive/Immune Titer Value ____________
 Equivocal/Borderline/Negative Titer Value ____________
(REQUIRES DOCUMENTATION OF TWO VACCINES – refer to page 2)
Attach copy of lab report (mail to SHS with all Immunization Forms)
Antibody Titers
Varicella IgG Titer
Month/Day/Year
Of Titer
____ / ____/ ____
Additional requirement
Note: Negative = equivocal,
borderline / negative; requires
proof of vaccination
#3 Rubella IgG Titer
Additional requirement
Titer Results
(Check appropriate box)
Note: Negative = equivocal,
borderline / negative; requires
proof of vaccination
#2 Mumps IgG Titer
Additional requirement
Titer Results
(Check appropriate box)
Corresponding number
for data entry at
https://lifenet.musc.edu
Note: Negative = equivocal,
borderline / negative; requires
proof of vaccination
#4 Varicella IgG Titer
 Positive/Immune Titer Value ____________
 Equivocal/Borderline/Negative Titer Value ____________
(REQUIRES DOCUMENTATION OF TWO VACCINES – refer to page 2)
Attach copy of lab report (mail to SHS with all Immunization Forms)
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Note: Negative = equivocal,
borderline / negative; requires
proof of vaccination
Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
Dose #1
Dose #2
____ / ____/ ____
____ / ____/ ____
Varicella (Varivax) Vaccine
Month/Day/Year
Of Vaccine
Signature (or stamp) of healthcare
professional
Print Name of Healthcare Professional
Address of healthcare
professional/facility
________________ / ____________
#6 Varicella
Immunizations
Leave blank if not
applicable. (i.e.
submitting immune
titers results.)
Telephone of healthcare
professional/facility
Tetanus/Diphtheria/Pertussis Vaccine
Documentation of an adult Tdap booster is required on or after 5/3/2005. If >10 years since receiving adult
Tdap vaccine, then documentation of a Td booster is required IN ADDITION.
Month/Day/Year
Vaccine
____ / ____/ ____
Signature (or stamp) of healthcare
professional verifying vaccination
Print Name of Healthcare
Professional
Address of healthcare
professional/facility verifying each
vaccination
#7 Adult TDAP
Enter date
administered.
Date must be
on/after 5/3//2005
Required field.
Telephone of healthcare
professional/facility
 Exception: Documented pertussis allergy – Attach letter from healthcare provider detailing the nature of your reaction.
(Leave on-line immunization form field blank if you have a documented pertussis allergy.)
Tetanus-diphtheria Vaccine (Td) required ONLY if > 10 years since adult Tdap Booster.
Month/Day/Year Of Vaccine
-----/-----/--------
Signature (or stamp) of healthcare professional verifying
vaccination
Print Name of Healthcare Professional
Address/Telephone of healthcare professional/facility
verifying each vaccination
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Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
________________ / ____________
Hepatitis B Vaccine Immunization
All clinical MUSC students are required to receive the hepatitis B vaccine series and submit an immune hepatitis B antibody titer
before beginning clinical rotations. (Not required for College of Graduate Studies and students in the MHA and DHA programs.) If
you previously received the vaccination series, you must provide documentation of the vaccine series and a copy of the lab report
documenting serologic evidence of immunity to hepatitis B. If you received the hepatitis B vaccine series during childhood and are
just now testing for immunity, if your hepatitis B surface antibody titer is negative or equivocal, you should receive a booster
(another hepatitis B vaccine) followed by a repeat antibody titer one month later. If these results are still negative or equivocal, you
will need to complete the series again (a total of two more hepatitis B vaccines at intervals of 0, 1, and 6 months.) After completion
of the series, you are required to return to Student Health Services for a final Hepatitis B Surface Antibody titer to determine your
immune status. Fees apply. Student Health Insurance does not bill your insurance company.





I need the Hepatitis B vaccine series. I will start it at another facility or will come to MSUC SHS prior to
classes starting to receive the first vaccine in the series of three. I understand I will not be considered
compliant with this requirement until SHS receives documentation that I have started the series. Fees
apply to Hep B immunizations received at SHS.
I previously completed the Hepatitis vaccine series and have attached a copy of the lab report of a positive
Hepatitis B Surface Quantitative Titer.
REQUIRED ATTACHMENT: lab report indicating a positive Hepatitis B surface antibody quantitative titer
or qualitative titer with numerical reference range.
I started the Hepatitis B vaccine series at another healthcare facility. I understand that I am responsible for
ensuring appropriate timing, administration, and follow-up of the entire series and will provide MUSC
Student Health Services with documentation of the series and a positive Hepatitis B surface antibody
quantitative titer.
REQUIRED ATTACHMENT: signed documentation of the vaccines administered to date
I started the Hepatitis B vaccine series and will complete the Hepatitis vaccine series at MUSC Student
Health Services. I understand that I am solely responsible for returning to Student Health Services when the
remaining injections are due. Fees apply.
REQUIRED ATTACHMENT: signed documentation of the vaccines administered to date
I previously completed one Hepatitis B vaccine series, but my Hepatitis B surface antibody quantitative titer
was not positive for immunity. I need additional Hepatitis B vaccines series to be administered by MUSC
Student Health Services during my first semester at MUSC. I will elect to either (a) repeat the entire 2nd
series including a post-series antibody titer or (b) receive one additional vaccine (“booster”) followed by a
repeat antibody titer at the time of injection. Fees apply.

I choose not to take the Hepatitis B vaccine series and will provide a waiver signed by my college dean.
REQUIRED ATTACHMENT: waiver signed by dean

I am a student in the College of Graduate Studies or a CHP MHA/DHA student and choose not to take the
Hepatitis B vaccine series. I have completed the on-line waiver at https://lifenet.musc.edu
Signature of Student
__________________________________________________
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# 8 and #9
Leave blank
#8 Hepatitis B Titer
#9 Hepatitis B
Immunizations
#9 Hepatitis B
Immunizations
# 8 and #9
Leave blank
# 8 and #9
Leave blank
# 8 and #9
Leave blank
Date ____________________________
Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
________________ / ____________
College/Program
Hepatitis B
(see page 15 for more information)
Month/Day/Year Of Vaccine
Dose 1
Dose 2
Dose 3
____ / ____/ ____
____ / ____/ ____
____ / ____/ ____
#16 Hepatitis B
Enter dates of
administration
Signature (or stamp) of healthcare professional
Leave blank if not
applicable. (DHA,
MHA and Graduate
Studies)
Print Name of Healthcare Professional
Address of healthcare professional/facility
Telephone of healthcare professional/facility
- 17-
Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
________________ / ____________
Tuberculosis Screening (Option A, B, or C)
Option A. Two Tuberculin Skin Tests (Intradermal Purified Protein Derivative / Mantoux 5TU)
Printed name AND Signature (or
#10 PPD-1
#1 PPD
(No more
than 90 days
prior to start
date)
#2 PPD
Place on
opposite
forearm,
7 – 10 days
after #1 PPD
Administered
___ / ___ / ___
Read
___ /___ /___
Administered
___ / ___ / ___
Read
___ /___ /___
Report results in mm only;
do not write “negative” or
“positive”
______ mm induration
______ mm erythema
stamp) healthcare professional
Address
Telephone
Enter date administered
Enter date read
Enter Result
(≥ 10mm induration =
positive; if < 10mm =
negative)
Enter mm induration
Leave blank if not
applicable.
Printed name AND Signature (or
stamp) healthcare professional
Address
Telephone
#11 PPD-2
* See below for additional
requirement if ≥ 10mm induration
Report results in mm only;
do not write “negative” or
“positive”
______ mm induration
______ mm erythema
* See below for additional
requirement if ≥ 10mm induration
Enter date administered
Enter date read
Enter Result
(≥ 10mm induration =
positive; if < 10mm =
negative)
Enter mm induration
Leave blank if not
applicable.
Option B. Interferon Gamma Release Assay (IGRA) blood test: QuantiFERON® TB Gold or T-SPOT
#12 Quantiferon Result:

Test date
TB Gold
 Positive
QuantiferonTB Gold
___ / ___ / ___
 Negative
REQUIRED - Attach copy of lab report
Leave blank if not
applicable.
 T-SPOT
Test date
___ / ___ / ___
Result:
 Positive
 Negative
REQUIRED - Attach copy of lab report
#13 T-Spot
Leave blank if not
applicable.
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Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
________________ / ____________
Option C. For students with a positive (≥ 10mm induration) TB skin test (current or previous)
Positive TB Skin Test
OR
Positive TB blood test
Month/Day/Year
___ / ___/ ___
______ mm induration
If no verifiable documentation for
positive TB skin test, then TB blood test
is required.
 Copy of Lab Report Attached
Chest x-ray
Prophylactic Treatment for
Positive PPD
#14 Chest X-ray
Month/Day/Year
Result:
___ / ___/ ____
 Attach copy of x-ray report
Enter date of
administration
Enter result
Leave blank if not
applicable.
 No
 Yes
Treated  INH  Other ________
Treatment Dates:
__/___/___ to ___/___/___
Start Date
Completion Date
Meningococcal Vaccine (Menactra or Menomune or Menevo or unknown)
 I do not wish to receive the meningococcal vaccine. I have read the information and completed the on-line form
at https://lifenet.musc.edu
Leave # 17 blank.
 Menactra  Menveo  Menomune  Unknown
Month/Day/Year Of Vaccine
____ / ____/ ____
Signature (or stamp) of healthcare professional
Print Name of Healthcare Professional
#17
Meningococcal
Vaccine
Enter date
administered.
Address of healthcare professional/facility
Telephone of healthcare professional/facility
End of Required Immunizations
The following Optional Vaccinations are recommended to students whose programs include
rotations at outside healthcare facilities and those planning foreign travel.
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Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
________________ / ____________
College/Program
OPTIONAL IMMUNIZATION DOCUMENTATION
Immunization requirements may vary for students doing clinical rotations at institutions outside MUSC or who will be participating in
foreign travel (e.g. medical mission trips, etc.) – some will require documentation of childhood vaccine series (Polio, DPT, etc.).
Having this documentation available will assist Student Health Services complete the necessary documentation to clear you for these
activities. If you anticipate participation in clinical activities outside MUSC and would like to have this documentation available,
please complete the following section (s).
Hepatitis A
Month/Day/Year Of Vaccine
Dose 1
Dose 2
____ / ____/ ____
____ / ____/ ____
Havrix
Vaqta
Havrix
#15 Hepatitis A
Enter dates of
administration
Vaqta
Leave blank if not
applicable.
Signature (or stamp) of healthcare
professional
Print Name of Healthcare Professional
Address of healthcare
professional/facility
Telephone of healthcare
professional/facility
Human Papilloma Virus (HPV)
Month/Day/Year Of Vaccine
Dose 1
Dose 2
Dose 3
____ / ____/ ____
____ / ____/ ____
____ / ____/ ____
Signature (or stamp) of healthcare
professional
Print Name of Healthcare Professional
#16 HPV
Enter dates of
administration
Leave blank if not
applicable.
Address of healthcare
professional/facility
Telephone of healthcare
professional/facility
- 20-
Last Name
____________________________________
First Name
____________________________________
Date of Birth (mm/dd/yy)
____________________________________
MUSC Student ID # (9 digits beginning with “90”) _________________________
Email address
____________________________________
College/Program
________________ / ____________
Diphtheria/Tetanus/Pertussis – Initial Childhood Series
Diphtheria/Tetanus/Pertussis –
Initial Childhood Series
Printed name AND Signature (or stamp) healthcare professional
Telephone
DPT / DTaP / TD (circle one)
Date Administered ____ / ____ / ____
#18 D/T/P
Childhood
Enter dates for each
dose.
DPT / DTaP / TD (circle one)
Date Administered ____ / ____ / ____
DPT / DTaP / TD (circle one)
Date Administered ____ / ____ / ____
DPT / DTaP / TD (circle one)
Date Administered ____ / ____ / ____
DPT / DTaP / TD (circle one)
Date Administered ____ / ____ / ____
Polio Series
Printed name AND Signature (or stamp) healthcare professional
Telephone
Polio
OPV
/
IPV
Enter dates for each
dose.
(circle one)
Date Administered ____ / ____ / ____
OPV
/
IPV
#19 Polio
(circle one)
Date Administered ____ / ____ / ____
OPV
/
IPV
(circle one)
Date Administered ____ / ____ / ____
OPV
/
IPV
(circle one)
Date Administered ____ / ____ / ____
OPV
/
IPV
(circle one)
Date Administered ____ / ____ / ____
Other Vaccines
Date (mm/dd/yyyy)
Partial dates are not accepted
Immunization Verified by Health Care Professional
- Printed name AND Signature or Stamp
Ditto marks, initials, and parental signatures are
not accepted. Please include telephone number.
Pneumococcal Vaccine
Pneumovax 0.5 cc
Pneumovax 0.5 cc
______ / ______ / ______
______ / ______ / ______
Other Vaccines
IPOL (Inactivated Polio Vaccine) 0.5cc Adult Booster
Typhoid Oral Vaccine (Ty21a) x 4 capsules
Typhim Vi (ViCPS) 0.5cc
Yellow Fever Vaccine (YF-VAX) 0.5cc
Miscellaneous Vaccines
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
Please attach any additional vaccines with vaccine/dates/verification information.
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