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Form Pitt 1557 - Data And Immunization Record Form - University Of Pittsburgh Student Health Service

OFFICE USE ONLY

PITT 1557 (0416)

CONFIDENTIAL

DATE ENTERED: ___________

ENTERED BY: ___________

UNIVERSITY OF PITTSBURGH STUDENT HEALTH SERVICE

DATA AND IMMUNIZATION RECORD

This form does not require a physician’s signature. The information can be filled in by the student or parent/guardian.

All information must be in English. Copies of original records are also acceptable. DO NOT SEND ORIGINAL RECORDS.

PART I: STUDENT INFORMATION

(ALL AREAS MUST BE COMPLETED)

STUDENT IDENTIFICATION NUMBER

DATE OF BIRTH

(Month/Day/Year)

NAME

(Last Name)

(First Name)

(Middle)

ADDRESS

(Street)

(City/State/Zip Code)

TELEPHONE

E-MAIL

PART II: REQUIRED

M.M.R. (MEASLES, MUMPS, RUBELLA)

(Two doses required. Titers are also acceptable as proof of immunization. A titer is a test that verifies immunity to a disease. A copy of titer results

must accompany this form for review. If you are sending titer results, you are not required to fill out MMR dates.)

___/___/___

DOSE 1:

(12–15 months or later)

___/___/___

(

DOSE 2:

4–6 years or later, and at least one month after first dose)

MENINGOCOCCAL QUADRIVALENT

One dose must have been administered when you were ≥ 16

#1 ____/____/____

#2_____/____/____

PART III: RECOMMENDED

TETANUS-DIPTHERIA

(Primary series with DTaP or DTP and booster with Td in the last 10 years meets requirement.)

PRIMARY SERIES OF FOUR DOSES WITH DTaP OR DTP:

#1 ___/___/___

#2 ___/___/___

#3 ___/___/___

#4 ___/___/___

___/___/___

TETANUS-DIPTHERIA

BOOSTER WITHIN THE LAST 10 YEARS:

(Td or Tdap)

POLIO

(Primary series in childhood meets requirement; three primary series schedules are acceptable.)

#1 ___/___/___ #2 ___/___/___ #3___/___/___

OPV ALONE

(oral Sabin three doses):

#1 ___/___/___

#2 ___/___/___

#3 ___/___/___

#4 ___/___/___

IPV/OPV

IPV

OPV

sequential:

#1 ___/___/___ #2 ___/___/___ #3 ___/___/___ #4 ___/___/___

IPV ALONE

(injected Salk four doses):

VARICELLA

(Either a history of chicken pox, a positive Varicella antibody, or two doses of vaccine given at least one month apart )

HISTORY OF DISEASE

YES ___

NO ___

___/___/___

VARICELLA ANTIBODY

REACTIVE ___

NONREACTIVE ___

___/___/__

___/___/___

IMMUNIZATION:

DOSE #1

DOSE #2

Form Pitt 1557 - Data And Immunization Record Form - University Of Pittsburgh Student Health Service

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