Health And Safety Documentation Form - Maricopa Community College District Allied Health Programs
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3MARICOPA COMMUNITY COLLEGE DISTRICT ALLIED HEALTH PROGRAMS
HEALTH AND SAFETY DOCUMENTATION
Home Phone:__________________ Cell Phone:__________________
Student ID
Number:_____________________
A.
MMR (Measles/Rubeola, Mumps, Rubella): Requires documented proof of two MMRs in lifetime or a
positive titer for each of these diseases.
st
nd
1
MMR Date: _______________
2
MMR Date: _______________
OR
Date and results of titer:
Measles/Rubeola _____________ Mumps ______________ Rubella
_____________
B.
Varicella (Chickenpox): Requires documented proof of two (2) vaccinations or positive IgG titer.
st
nd
1
Varicella Date: ______________
2
Varicella Date: ______________
OR
Date & results of IgG titer:___________________________________________
C.
Tetanus/Diphtheria (Td) immunization within the past 10 years.
Td Date: ____________________
D.
Tuberculosis:
Two-Step Testing** for initial skin testing of adults who will be retested periodically
TWO-STEP TESTING
Use two-step testing for initial skin testing of adults who will be retested periodically.
- If first test positive, consider the person infected.
- If first test negative, give second test 1-3 weeks later.
- If second test positive, consider person infected.
.
- If second test negative, consider person uninfected
- If both parts of Two step test are negative then subsequent testing is done annually with one step
procedure
INITIAL TEST:
Test Given_______________Date Read___________Result_____________________________
SECOND TEST (1-3 weeks after initial test):
Test Given:
Date Read: _________ Result_____________________________
OR
Annual TB skin test (PPD):
Test Given______________ Date Read___________Result_____________________________
OR
Previous Positive PPD test:
Provide documentation of negative chest x-ray/evidence of TB disease free status
Date of chest x-ray____________________Result____________________________________
*If applicant has ever had a positive reaction, the test is not to be repeated. Other evidence that the applicant is free from
Tuberculosis will be required.
**Core Curriculum on Tuberculosis What the Clinician Should Know, Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination,
th
Atlanta, Georgia, 4
Edition, 2000.
08/26/09
Page 16 of 18
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