Health History & Physical Examination Form - Suny Poly Page 4
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4IMMUNIZATION RECORD
Health Care Provider Completes
Student Name ______________________________________________________ Birth Date ___ ___-___ ___-___ ___ ___ ___
Month/
Initials of
Physician diagnosed
certifying health
disease history
Titers
Day/Year
professional
(date of onset)
MMR Combined Vaccine
#1
Laboratory Report with
lab values MUST be
(
REQUIREMENTS AS NOTED BELOW )
attached
#2
OR
MEASLES:
#1
TWO DOSES ARE REQUIRED
Laboratory Report with
If born after 1/1/57, 2 doses LIVE vaccine: #1 no more than 4 days
lab values MUST be
prior to the first birthday, #2 at least 30 days after the first dose.
#2
Positive titer with numeric result or physician documentation of having
attached
the disease are acceptable in lieu of the vaccine.
MUMPS:
ONE DOSE REQUIRED
Laboratory Report with
If born after 1/1/57, 1 dose LIVE vaccine given AFTER the first
lab values MUST be
birthday. Positive titer with numeric result or physician documentation
of having the disease are acceptable in lieu of the vaccine.
attached
Nursing students require 2 doses.
RUBELLA:
Laboratory Report with
ONE DOSE REQUIRED
Not Acceptable
lab values MUST be
If born after 1/1/57, 1 dose LIVE vaccine given AFTER the first
attached
birthday. Positive titer with numeric result is acceptable in lieu of the
Nursing students require 2 doses
vaccine.
MENINGOCOCCAL MENINGITIS:
A SUNY Poly provided Meningococcal
OR
ONE DOSE REQUIRED
Meningitis Response Form MUST be
Completed Meningococcal Meningitis Response Form
completed by the student in lieu of the vaccine.
indicating declination of a Meningococcal Meningitis vaccine
REQUIRED FOR DEPARTMENT OF NURSING STUDENTS, recommended for all other students:
TETANUS/DIPTHERIA:
Updated with DTaP every 10 years
VARICELLA
#1
Laboratory Report with
:
lab values MUST be
E
ither 2 vaccines or positive titer with numeric result
attached
#2
HEPATITIS B
#1
:
Laboratory Report with
Either 3 vaccines or a positive titer with numeric result
lab values MUST be
#2
attached
#3
ANNUAL INFLUENZA VACCINE
ANNUAL TUBERCULOSIS TESTING:
Mantoux: Date Placed________ Date Read__________ Results __________ mm
QuantiFERON TB-GOLD or T-Spot: Date ________ Negative____ Positive ____
Mantoux, QuantiFERON TB-GOLD or T-SPOT
If positive: Chest X-Ray Date _____________
Results ____________
A positive Mantoux, QuantiFERON TB-GOLD or
Diagnosis: Latent TB or Active TB
T-SPOT REQUIRES further testing with
Was treatment offered? Yes _______ No _______
documentation.
Treatment & Date Completed___________________________________________
Signature of Health Care Professional __________________________________________________ Date _________________
Return to: SUNY Poly Health & Wellness Center 100 Seymour Road Utica, NY 13502 Fax: 315.792.7371
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SD: New Student/PE Form 5-15
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