Sample Student Health Record Form (Page 2 of 2) in pdf

IMMUNIZATION RECORD

To be able to register for classes, each section that is applicable to the student must be filled out. A health care provider must sign the bottom of the form

OR a copy of an immunization record must be attached to validate the dates of each vaccine listed.

Full Name

Date of Birth

A. MEASLES, MUMPS AND RUBELLA

The State of Tennessee requires all students, born after 1956, entering college to provide proof of two (2) doses of Measles, Mumps, and Rubella (MMR)

vaccine on or after the first birthday and at least 28 days apart. Proof of immunity by IgG titer to all three diseases is also accepted.

REQUIRED for ALL students born after 1956. MMR (measles, mumps, rubella).

Combined shot (date given): MMR #1 __/__/__ MMR #2 __/__/__ OR Titer showing immunity date: __/__/__ Results:

B. HEPATITIS B

Hepatitis B is a serious viral infection that can lead to chronic liver disease, liver cancer, liver failure and even death. It is contracted through exposure to

infected blood and through body fluids that may contain blood. This disease is preventable by vaccination. A series of three (3) doses of the vaccine are

required for optimal protection. Missed doses may still be sought if only one or two have been acquired. The HBV vaccine has a record of safety and is

believed to confer lifelong immunity in most cases.

REQUIRED for student pharmacists and nursing students. ALL other students must provide proof of vaccination OR waiver below.

Hepatitis B (HBV) immunization (date given): #1 __/__/__ #2 __/__/__ #3 __/__/__

o I decline receipt of vaccine to protect for Hepatitis B. Student’s Signature

Parent/Guardian Signature (if student is not 18 years of age)

C. MENINGITIS

Meningococcal disease is a rare but potentially fatal bacterial infection, expressed as either meningitis (infection of the membranes surrounding the brain

and spinal cord) or meningococcemia (bacteria in the blood). College students, especially freshmen living in residence halls, are at an increased risk for

contracting meningococcal disease. The bacterial form of this disease can lead to serious complications such as swelling of the brain, coma, loss of limbs and

even death in a short period of time. The disease strikes about 3,000 Americans each year and is responsible for about 300 deaths annually. Immunization

can prevent up to 80% of meningococcal meningitis in the United States and for the majority of the cases in the university population. The vaccine is

considered safe and effective against 4 of the 5 types of bacteria responsible for meningococcal meningitis. For more information regarding meningitis go to

Vaccination OR waiver REQUIRED for ALL students living in a residential hall.

Meningitis vaccine (date given): __/__/__

o I decline receipt of vaccine to protect for meningococcal. Student’s Signature

Parent/Guardian Signature (if student is not 18 years of age)

D. VARICELLA

As of July 2011, the State of Tennessee requires ALL students born after 1979 to have documented date of chickenpox disease OR two (2) varicella vaccinations

OR proof of immunity by positive IgG titer. Student pharmacists and dietetic interns MUST show immunity with a titer.

Date of disease: __/__/__ OR Two (2) Varicella immunizations (date given): #1 __/__/__ #2 __/__/__ OR Titer showing immunity date: __/__/__

E. TUBERCULOSIS (TB) SCREENING (Must be within 12 months prior to enrollment).

Option 1 OR 2 is REQUIRED for ALL NEW students and Option 1 is REQUIRED for student pharmacists and dietetic interns.

Option 1: PPD (TB skin test) or Interferon Gamma Release Assay (IGRA)

Date given: __/__/__ Given by (initials):

Date read: __/__/__

Results: PPD:

mm of induration OR IGRA: o positive o negative o intermediate

Option 2: Fill out the TB Assessment Form (separate form) and sign the bottom. If you have risk factors, an appropriate TB screening test is necessary.

F. TETANUS

Suggested for ALL NEW students and REQUIRED for student pharmacists and nursing students.

Date given (within past 10 years): __/__/__

circle one:

Tdap

I certify that this student has had the immunizations above.

Health Care Provider Signature:

Date:

Printed name:

Phone:

05.2011