Student Volunteer Immunization Review Form printable pdf download

Student Volunteer Immunization Review Form

All information must be completed. We will not accept immunization records in lieu of this form

and we do not have access to records at UNC or Student Health.

Name:

1. MEASLES, MUMPS AND RUBELLA (MMR) DATES

MMR#1

MMR#2

MEASLES

)

(Vaccine or titer

MUMPS

)

(Vaccine or titer

RUBELLA

)

(Vaccine or titer

Indicate history of two live measles, two mumps and two rubella immunizations (or titer)

2. CHICKEN POX (VARICELLA)

Did you have the Chicken Pox?

Yes

Unknown

If you received a titer, date of known serologic immunity?

If you answered “No” or “Unknown”, you must receive the Varicella Vaccine prior to

volunteering.

and

Received Varicella Vaccine

Dates #1

(everyone may not have 2

vaccine)

3. TETANUS, DIPHTHERIA AND ACELLULAR PERTUSSIS (Tdap)

Date received

4. FLU VACCINE DATE

UNC Health Care Policy requires all volunteers working from Jan-May to have a yearly flu

vaccine.

Only for Spring Volunteering

5. TUBERCULOSIS SKIN TESTING

UNC Health Care Policy requires all new volunteers to have a TB skin test (or TB blood test)

within the past 12 months unless contraindicated. Please provide Volunteer Services with a

copy of your TB results or have a health care provider document results below.

Date Placed_________

Strength_____Lot#_______

Date Read

Result

(in mm of induration)

If you have had a reactive PPD/IGRA (TB blood test) please provide the following information:

Size of induration of last PPD______________________Date

Results of TB blood test (IGRA)____________________Date______________________

Chest Xray documentation________________________Date

History of BCG vaccine Yes____No_____Place of birth__________________________

Treatment with INH or other TB medications_______________How long?

For TB Test:

Name of Health Care Facility

and Health Care Provider Signature

Department of Volunteer Services UNC Hospitals 101 Manning Drive, Chapel Hill, North Carolina 27514

7/14

Telephone: (919)966-4793 * Fax: (919)966-1389

Student Volunteer Immunization Review Form

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