REQUIRED INFORMATION FORM- FOR FACULTY, STUDENTS & CONTRACT STAFF
NAME: ___________________________
HOME PHONE: _______________________
CMC ROTATION DATES: ___________
SCHOOL: _____________________________
ADDRESS: ________________________
CITY: ________________________________
FACULTY: ________________________
SCHOOL PHONE: ______________________
Please provide the following information – submit at least 1 week before the start of clinical rotation.
1.
You must have a negative TB test (TST) within the last 12 months prior to your clinical rotation. If you have had
a positive TB test, you must have a negative chest x-ray within the last 5 years. If positive, include mm
(millimeters) of induration ________ mm.
TB Test:
Date: ________ Positive ______mm induration (if TB skin test) Negative ______
Chest X-Ray: Date: ________ Positive _______ Negative ______ (please attach x-ray report)
2.
Date of birth:__________________ Have you had the chickenpox (Varicella)? _____ yes ______no.
If NO or if you were born in or after 1980, you must have two doses of Varivax vaccine or a positive titer:
Dose #1_________ Dose #2_________ Varicella titer date____________result__________________
3.
EVERYONE must demonstrate immunity to measles, mumps, and rubella.
A. Were you born prior to January 1, 1957?
If YES:
 have you had the Measles (Rubeola)?
 have you had the Mumps?
____yes ____no.
____yes ____no.
____yes ____no.
******If no history of disease, date of MMR vaccine _________******

Must have rubella vaccination or positive titer – vaccine date_______ titer date/result____________
B. If NO: (born after 1-1-1957)
 Must have 2 MMR vaccinations or positive titers to all three
Measles vaccine or titer date ______ titer result _______
Rubella vaccine or titer date______ titer result _______
Mumps vaccine or titer date______ titer result _______
OR
_
MMR #1 _________ date
MMR#2 __________ date
You must have 2 doses of measles (rubeola) vaccine, 2 doses of mumps vaccine and 1 dose of rubella
vaccine or 2 MMR’s or have evidence of immune titers for all three
4.
Have you had the Hepatitis B Vaccine? _______
Date of last dose ____________Dose # _______
5.
Date of CPR expiration _____________ Course Type _________________
6.
Have you viewed the Children’s Annual Training Video (CART) and completed the post-test?
_____yes _______no
7.
Record of a Td (Tetanus/Diphtheria) or Tdap (Tetanus/Diphtheria/Pertussis) within the past ten years. If in
direct patient care, must have received one dose of Tdap vaccine. Date_________ Td / Tdap (please circle).
8.
Influenza vaccination (required annually)
Revised 09-20-11 C Amrich
if yes, how many doses have you received? ____________
Vaccine immune titer date & results _________________
Date___________________________