Wppd Mandatory Immunization Health History Form

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WPPD MANDATORY IMMUNIZATION
HEALTH HISTORY FORM
Name: ________________________________________
_________________________________________________________
(Print)
Last
First
Date of Birth: ____ ____ ____
Student ID# __________________________ UF Study begins: ______________ ________
Month
Day
Year
Semester
Year
Phone: (____) _________________ Email: __________________________________
Carefully read the instructions before you complete the form. Registration at UF will be blocked until this document is received and acceptable.
A. Immunization Required for ALL Students
New Requirements for ALL Students Entering UF
(See instruction sheet for acceptable vaccine date explanations)
4. Menomune or Menactra (for meningococcal meningitis)
or
1. MMR (Measles/ Mumps (See “D.”) /Rubella)
Date:
Read information on Instruction
Month Day Year
sheet and check-off & sign waiver, below.
Dose: 1
2
______ I have read the information provided and I decline receipt of vaccine for
Month Day Year
Month Day Year
meningococcal meningitis.
Or 2. Measles (Rubeola)
______________________________________________ _________________
Signature of Student
Date
or
Dose: 1
2
Hepatitis B vaccine is mandatory for your acceptance into the Pharm D.
Month Day Year
Month Day Year
Titer/Date - Attach copy of IGG titer lab report
5. Hepatitis B vaccine
Dose: 1
Month Day Year
Month Day Year
and 3. Rubella (German Measles)
or
Dose: 2
Dose: 3
Month Day Year
Month Day Year
Month Day Year
Titer/Date - Attach copy of IGG titer lab report
or: Attach “IGG” Titer Lab Report results indicating Proof of Immunity
Month Day Year
B. Immunizations Required for International Students & Academic Health Programs (Incl. COLLEGE OF PHARMACY)
6. Tuberculosis Skin Test (PPD by Mantoux current within the past year)
If positive PPD
Must send copy of
Date Placed
Date Read
Result (Record in mm) NEG POS
,
date of chest x-ray
chest x-ray report!
_____ _____
Month Day Year Month Day Year
Month Day Year
C. Immunization required for many Academic Health Programs (Incl. COLLEGE OF PHARMACY)
7. Varicella (Chicken Pox)
Attach copy of IGG titer lab report
History of Disease
Varivax Dose
or
Titer/Date
or
: 1
2
Month Day Year
Month Day Year
Month Day Year
Month Day Year
D. MANDATORY for ALL College of Pharmacy WPPD Students
8. Tetanus/Diphtheria (Booster within last 10 years)
Tdap(Tetanus/Diphtheria/Pertussis)
9. Mumps
Date:
OR
Date:
Date:
Month Day Year
Month Day Year
Month Day Year
E. An OFFICIAL STAMP from a doctor’s office, clinic, or health department AND an AUTHORIZED SIGNATURE must appear here or this form will
not be approved.
_________________________________
__________________________________________________
______________________
Public Health Clinic or
Physician or Authorized Signature
Date
Physician (OFFICIAL STAMP)
Send or fax form with lab reports prior to registration to:
University of Florida/WPPD Program
Fax: 352-273-6593
Off-Site Admissions Office
Call: 352-273-6280 with questions
2145 MetroCenter Blvd, Suite 400
Orlando, FL 32835-6217
(Updated September 2009)

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