UCDHS HEALTH CLEARANCE CRITERIA
Students, rotators, affiliate’s or trainee’s must provide documentation to Training and Development.
Students, rotators, affiliate’s or trainee’s must see their own Primary Care Physician (PCP) or clinic for
immunizations.
MANDATORY
 Mandatory
MEASLES (RUBEOLA) Criteria:
Proof of immunity to measles. Acceptable criteria:
 Positive serology for Antibody to Measles is required (copy of lab slip)
OR
 Documentation of TWO measles shots in a lifetime.
 Mandatory
RUBELLA (GERMAN MEASLES) Criteria:
Proof of immunity to Rubella. Acceptable criteria:
 Positive serology for Antibody to Rubella is required (copy of lab slip)
OR
 Documentation of TWO immunizations for Rubella (MMR, MR, Rubella
immunization).
 Mandatory immunity
VARICELLA (CHICKEN POX) Criteria:
Proof of immunity to Varicella. Acceptable criteria:
Varicella (VZ) by serology, not history (copy of lab slip)
OR
 Or two Varivax injections – will be given quarantine policy if non-immune.
Mandatory immunity or declination
MUMPS
Proof of immunity to Mumps. Acceptale criteria:



Documentation of TWO MMR’s in a lifetime
OR
Positive serology antibody for mumps ( copy of lab slip )
Or sign a declination
 Mandatory immunity or declination
Hepatitis B only for employees at risk of Bloodborne exposure – (exception - volunteers
are not eligible, only if in CLA class)
 EHS requires all three (3) doses of Hepatitis B vaccine.
 EHS requires a Hepatitis B surface antibody test ( CDC states a quantitative number
value of ‘10’ represents life time immunity – lab values that are positive – may or may
not reflect this)
Per UCDHS EHS: Health Clearance, updated 10/1/2010
S:HR/Training/Students/Health Clearance for Externs
 Mandatory
Tuberculosis (TB) Criteria:
 Evidence of PPD skin test results within the last 6 months. 2 Step required.
 A 2 step PPD is where the student(s) will go to their own doctor/clinic to get it done, read
and then a few days or weeks (depending on the clinic and their availability) later, the
student will go back and get it done again and read again two days later. Both must be
done within a year and both must be read negative to be considered clear.
→ Or Quantiferon lab result within 1 year
a. QuantiFERON Gold (QFT-G) is accepted in place of a PPD standard skin test (TST):
-Accepted within one year
-If QFT –G is negative nothing else is needed
- If QFT-G was positive, it is required you have a symptom interview and chest x-ray
within 6 months.
 If individual is already PPD Positive:
 Evidence of a chest x-ray within the last 6 months and interview the participant for TB
symptoms (symptom interview).
TB clearance is required annually for all health care providers by either a skin test or a symptom interview.
Influenza Immunization
 Mandatory Seasonal Flu vaccine – is offered yearly
Evidence of vaccination from elsewhere or vaccinated here at EHS/UCDMC
OR
Declination
All student externs working at UC Davis Medical Center (UCDMC) or within the UCD Health System are required to obtain a
Seasonal Flu Vaccine at the beginning of each influenza season and at other times in which high risk is identified by the
UCDMC Infection Prevention Officer. The influenza season is usually September through March of each year; therefore
all student externs who begin their externship from September through March will be required to comply with this requirement.
Seasonal Flu Vaccines are good for six months. Student externs must obtain their seasonal flu vaccination from their own
primary care physician or some other outside source and provide document confirming that they have been vaccinated.
Student externs may choose to decline the season flu vaccination if they have a religious or medical reason. If they decline,
they must complete and sign a Declination Form which should be fax with their paperwork. Students who decline may be
required to wear a mask in designated areas and at specified times, as determined by the UCDMC Infection Prevention
Officer.
Per UCDHS EHS: Health Clearance, updated 10/1/2010
S:HR/Training/Students/Health Clearance for Externs
Influenza Vaccine Declination 2010-2011
Influenza and H1N1 has been combined into one vaccination. Students are required to go to their own physician
or clinic for all immunization.
Written declination is required by new California law (SB 739) beginning in 2007
I acknowledge that I am aware of the following facts:
•
•
•
Influenza is a serious respiratory disease that kills, on average, 36,000 Americans every year.
Influenza virus may shed for up to 48 hours before symptoms begin, allowing transmission to others.
Up to 30% of people with influenza have no symptoms, allowing transmissions to others.
Flu virus changes often, making annual vaccinations necessary. Immunity following vaccination is strongest for
2 to 6 months. In CA, influenza usually arrives around January first through February or March.
•
I understand that flu vaccine cannot transmit influenza. It does not, however, prevent all disease.
•
I have declined to receive the influenza vaccine for the 2010-2011 season. I acknowledge that influenza
vaccination is recommended by the CDC for all healthcare workers to prevent infection from and transmission of
influenza and its complications, including death, to patients, my coworkers, my family, and my community.
Knowing these facts, I choose to decline the vaccination at this time.
I may change my
mind and accept the vaccination later, if vaccine is available. I have read and fully understand the information on this
declination form.
Print Name ________________________________________________________________
Legal name; including entire hyphenated name
Dept. ____________________________________________
Date: _______________
Signature _________________________________________________________________________
STOP * Read Carefully
I have had a flu shot 2010 -2011.
Clinic where vaccinated _____________________________________ Date vaccinated _________________
Print name_______________________ Signature ___________________________
Legal name;
including entire hyphenated name
Date signed _______________________________
You will be counted as vaccinated!! Please provide proof of your vaccination. Thank
you.
Per UCDHS EHS: Health Clearance, updated 10/1/2010
S:HR/Training/Students/Health Clearance for Externs
Non-Mandatory:
TETANUS Immunization:
If more than 10 years ago, EHS recommends tetanus immunization update.
HEPATITIS B:
EHS recommends Hepatitis B vaccine. For participants who have completed Hepatitis B vaccine,
EHS recommends a Hepatitis B surface antibody test. Booster dose is recommended for titres
below 10 I.U.
 RECOMMENDED - TDAP ( once in a lifetime booster for Whooping cough)
OR - signed declination - Mandatory
 Antibody only for employees at risk of Bloodborne exposure C
Tested by serology (This does not preclude the employees or volunteers ability to work if positive – stays
confidential)
Per UCDHS EHS: Health Clearance, updated 10/1/2010
S:HR/Training/Students/Health Clearance for Externs
STIX ID____________
TDAP VACCINE DECLINATION
I understand Pertussis protection has waned since my childhood immunization series to DPT. I may have lost my
immunity to Pertussis (whooping cough). I am at risk of acquiring Pertussis, a serious disease and could potentially
infect others. I understand this is a once in a lifetime booster. I have been given the opportunity to be vaccinated
with TDAP vaccine at my doctor’s clinic. I decline TDAP. If I should acquire this serious disease, it is my
responsibility to see my PCP for treatment, call employee health services at 916-734-3572 and infection control
dept. at 916-734-3377. If I change my mind and have no contraindications, I must go to my own primary care
physician to get the immunization.
_______ I had an allergic reaction to Pertussis vaccine as a child
_______ I was vaccinated with Td less than 2 years ago
_________________________________
Name (please print)
______________________________
School Coordinator/Instructor Witness
____________
DOB
___________________________
Date:
Signature: (Confirms receiving and agreeing to the content of this letter)
Per UCDHS EHS: Health Clearance, updated 10/1/2010
S:HR/Training/Students/Health Clearance for Externs
Stix ID____________
MUMPS VACCINE DECLINATION
I understand my Mumps antibodies’ protection has waned since my childhood immunizations. I have lost my
immunity to Mumps. I am at risk of acquiring Mumps, a serious disease and I could potentially infect others. I
have been given the opportunity to be vaccinated with the Mumps vaccine at no charge. I decline the Mumps. If I
should acquire this serious disease, it is my responsibility to see my (Primary Care Physician) PCP for treatment,
call employee services at 916-734-3572, and infection control department at 916-734-3377. If I change my mind
and have no contraindications, I must go back to my PCP to receive the immunization.
______________________________
Name (please print)
_____________________________
School Coordinator/Instructor Witness
______________
DOB
____________________________
Date:
Signature: (Confirms receiving and agreeing to the content of this letter).
Per UCDHS EHS: Health Clearance, updated 10/1/2010
S:HR/Training/Students/Health Clearance for Externs