Required Immunizations Form printable pdf download

The Employee Health and Well-being department of The University of Texas M. D. Anderson Cancer

Center requires all educational trainees to provide documentation of immunizations or serological

proof of immunity to varicella. Baseline screening for Tuberculosis (TB) is also required. This consists of

the following:

• TB test within the previous 12 months or

• Documentation of a previously positive TB skin test. If there is documentation of a positive TB

skin test (over 10 mm induration.), a chest x-ray report completed after the positive TB test, must

be provided. Previous BCG vaccination does not contraindicate receiving a TB skin test.

Please submit an immunization record using the form provided by M. D. Anderson Employee Health and

Well-being. Include complete dates of immunizations requested in all fields (month, day and year),

and attach all applicable lab reports and x-rays. The form must be signed by a physician or an

authorized health care provider

• Please note that additional documentation of immunizations may be required for

specific programs. MD Anderson Cancer Center encourages all educational trainees

to have a complete immunization record, which would include vaccines for measles,

mumps and rubella, a booster dose of tetanus/ diphtheria or tetanus / diphtheria/

pertussis within the previous 10 years. Hepatitis B vaccine is also recommended for

those trainees who will have direct patient contact or contact with blood or body fluid.

Frequently asked questions

What should I do if I don’t have immunization records?

You can either repeat the vaccinations or have your medical provider obtain a blood sample to test for

serological confirmation of immunity. (Please send lab reports with your immunization record.)

I have had varicella (chicken pox), but I don’t have any record. What should I do?

Employee Health and Well-being will accept a verbal self-report of varicella.

What if I don’t know if I have had varicella (chicken pox)?

If you are you’re not sure you have had chicken pox, the infection, a blood test will indicate if you have

immunity. If you don’t have immunity, you will need two doses of vaccine at least one month apart.

Can I get the immunizations in the Houston area?

There are clinics close to M. D. Anderson that can administer needed vaccines; the attached

Immunization Resources sheet lists several of these clinics. The individual student will be responsible for

the required fees.

Georgia Thomas, MD, MPH

Executive Director, Employee Health & Well-being

Professor, Department of Infectious Diseases, Infection Control, and Employee Health

Unit 631 - UT M.D. Anderson Cancer Center

Houston TX 77230-1402

Required Immunizations Form