Seoul National University Health Form
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1Seoul National University Health Form
Name
:
(please print)
Last
First
Middle
Date of Birth :
Nationality : ____________________
/
/
Email : _______________________ Telephone : ____________________
Seoul National University requires all students to be immunized against certain communicable diseases. To comply have
this form completed and signed by your health care provider and submitted to the SNU ISI Team by uploading on the
online application. Please bring the original signed form with you when you arrive at SNU dormitory.
1. Immunizations
Required
Dates Given
Requirements
(Month/Day/Year)
Two doses at age ≥ 12 months,
Measles-Mumps-Rubella (MMR)
#1____/____/______
#2____/____/______
at least 28 days apart. History of
If administered separately or positive
month day year
month day year
disease is not acceptable
titers obtained, record below
Measles
Date #1 ____/____/____ #2____/____/______
Two doses or positive titer
(Rubeola)
OR Positive titer_______ Date:____/____/____
Mump
Date #1 ____/____/____ #2____/____/______
Two doses or positive titer
OR Positive titer_______ Date:____/____/____
Date #1 ____/____/____ #2____/____/______
Two doses or positive titer
Rubella
(German Measles)
OR Positive titer_______ Date:____/____/____
Recommended*
Dates Given
Recommends
(Month/Day/Year)
Two doses at age ≥ 12 months,
Varicella
Date #1 ____/____/____ #2____/____/______
at least 28 days apart.
OR Positive titer_______ Date:____/____/____
One dose within the past 10 years
Tetanus/Diphtheria/Pertussis
(Tdap) Date: ____/____/_______
Hepatitis B
Dose #1, any age
#1 ____/____/________ #2 ____/____/______
Dose #2, 1-2 months after dose #1
#3 ____/____/________
Dose #3, 6 months after dose #1
Hepatitis A
#1 ____/____/________ #2 ____/____/______ Dose #2, 6 months after dose #1
Meningococcal
Date: ____/____/_______
* Recommended vaccinations are available at SNU Health Service Center at own expense after arrival. Required vaccinations should be given prior to arrival.
2. Tuberculosis Screening
PPD test OR chest X‐ray (CXR) must be done within one calendar year prior to your Seoul National University
admittance. History of BCG vaccination does not prevent PPD testing.
PPD:
□ Negative □ Positive
/
/
/
/
Date placed
Date read
# of mm induration**
** If PPD results are 10mm or more, a chest X‐ray is REQUIRED.
OR
Chest X‐ray:
Result: □ Normal □ Abnormal Finding:
/
/
Date
Please attach chest X-ray report in English
If PPD test is/was positive or CXR is positive, did student complete a course of antibiotic therapy?
□ YES
Drug, Dose, Frequency, Duration and Dates
□ NO
Please document reason prophylaxis or treatment not done
PROVIDER INFORMATION REQUIRED
Stamp of hospital/clinic
Physician’s Name (please print)
Signature
License No
Date(M/D/Y)
Clinic/Institution:
Address:
Phone number:
Fax number:
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