Form Pitt 1557 - Data And Immunization Record Form - University Of Pittsburgh Student Health Service Page 2

QUADRIVALENT HUMAN PAPILLOMAVIRUS VACCINE

(Three doses of vaccine)

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DOSE 1:

DOSE 2:

DOSE 3:

HEPATITIS B

(Three doses of vaccine or two doses of adult vaccine in adolescents 11–15 years of age, or a positive Hepatitis B surface antibody)

IMMUNIZATION

(Hepatitis B)

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DOSE 1:

DOSE 2:

DOSE 3:

IMMUNIZATION

(Combined Hepatitis A and B Vaccine)

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DOSE 1:

DOSE 2:

DOSE 3:

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HEPATITIS B SURFACE ANTIBODY:

RESULT

REACTIVE ___

NONREACTIVE ___

HEPATITIS A

IMMUNIZATION

(Hepatitis A)

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DOSE 1:

DOSE 2:

IMMUNIZATION

(Combined Hepatitis A and B Vaccine)

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DOSE 1:

DOSE 2:

DOSE 3:

PART IV: FOR HIGH-RISK GROUPS ONLY

(Categories of high-risk students include those students who have arrived within the past five years from countries where TB is endemic. Other categories of high-risk students include those with HIV infection;

who inject drugs; who have resided in, volunteered in, or worked in high-risk congregate settings such as prisons, nursing homes, hospitals, residential facilities for patients with AIDS, or homeless shelters; and

those who have clinical conditions such as diabetes, chronic renal failure, leukemias or lymphomas, low body weight, gastrectomy and jejunoileal bypass, chronic malabsorption syndromes, prolonged

corticosteroid therapy (e.g., prednisone 15 mg/d for one month) or other immunosuppressive disorders.)

PNEUMOCOCCAL POLYSACCHARIDE VACCINE

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TUBERCULOSIS SCREENING

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TUBERCULIN SKIN TEST:

DATE GIVEN

DATE READ

: ______

RESULT

(Record actual mm of induration, transverse diameter; if no induration, write “0”)

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INTERPRETATION

:

POSITIVE

NEGATIVE

(based on mm of induration as well as risk factors)

CHEST X-RAY

(Required if tuberculin skin test is positive)

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RESULT:

NORMAL

ABNORMAL

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DATE OF CHEST X-RAY:

PART V: IMMUNIZATION EXEMPTIONS

A written exemption statement must be returned to the Student Health Service for review. Please be aware, if an outbreak of measles, mumps, or rubella occurs, the State Health Department may exclude

students from classes who do not provide proof of immunity to these diseases.

If applicable, please check one of the following immunization exemptions:

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MEDICAL

(An exemption may be granted based on a written statement from a physician, or a designee, that the immunization(s) may be detrimental to the health of the student.)

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RELIGIOUS/MORAL/ETHICAL

(An exemption may be granted based on a student’s written objection to the immunization on religious grounds or on the basis of a strong moral or ethical conviction

similar to a religious belief.)

Student Health Service, 119 University Place, Nordenberg Hall, Pgh, PA 15260

Phone #: 412-383-1800

FAX#: 412-383-1846