Required Immunization Form For Graduate Students
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1
2REQUIRED IMMUNIZATION RECORD
To Be Completed By Health Care Provider
Name:
Date of Birth:
Student ID #:
THE FOLLOWING IMMUNIZATIONS ARE REQUIRED BY RI DEPARTMENT OF HEALTH FOR ALL STUDENTS
DPT/DT/TDAP
Must have one (1) Tdap & also last dose of Td or Tdap must be within last 10 years
MMR
Two doses of MMR (Measles, Mumps, Rubella) both given after 12 months of age, or disease confirmed
by office record or positive titre
VARICELLA
One dose after 1 year of age, or two doses after 13 years of age, or disease confirmed by office record or
(chicken pox)
positive titre
HEPATITIS B
Three doses Hepatitis B vaccine required, or positive titre (or two adult doses between the ages of 11-15)
MENINGITIS VACCINE
One dose of meningococcal conjugate (MCV4) vaccine is required for students previously unvaccinated
(under 22 years of age). A second booster dose is required if the first dose was given before 16 years of age.
THE FOLLOWING VACCINES ARE REQUIRED INCLUDING DATES (MM/DD/YY) OF IMMUNIZATIONS OR POSITIVE TITRE.
IMMUNIZATION
Date of Td booster
Tdap booster
or
within 10 years
within 10 years
DPT/TD
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
MMR Titre
Titre Results
MMR
Date and Results
*2 doses required
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Date of Disease
Measles Titre
Titre Results
Measles
Date and Results
_____/_____/_____
_____/_____/_____
Titre Results
Date of Disease
Mumps Titre
Mumps
Date and Results
_____/_____/_____
_____/_____/_____
Date of Disease
Rubella Titre
Titre Results
Rubella
Date and Results
_____/_____/_____
_____/_____/_____
Hepatitis B Titre
Titre Results
Date and Results
Hepatitis B
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Date of Disease
Varicella Titre
Titre Results
Date and Results
Varicella
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
Meningococcal Vaccine
(MCV4)
_____/_____/_____
_____/_____/_____
THE FOLLOWING VACCINES ARE STRONGLY RECOMMENDED BUT NOT REQUIRED.
HPV Vaccine
_____/_____/_____
_____/_____/_____
_____/_____/_____
TUBERCULIN SKIN TEST - PPD (Mantoux) required within the past year if high risk.
IGRA/QUANTIFERON RESULT
Risk Assessment: Must complete tuberculosis questionnaire insert to determine risk.
Date
q
q
q
LOW RISK. PPD not required.
HIGH RISK.
BCG VACCINE:
Date
PPD (MANTOUX)
Date Given
Date Read
Results
Chest X-ray (if PPD is positive)
Date:
_____/_____/_____
_____/_____/_____
Results:
_____/_____/_____
_____/_____/_____
Treatment:
_____/_____/_____
_____/_____/_____
HEALTH PROVIDER INFORMATION:
Name (print):
Phone Number:
Address:
Signature of Health Provider:
Date:
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