Doctors Hospital - Ohiohealth Immunization Form
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1
2Doctors Hospital- OhioHealth
Updated Record of Required Immunizations - 4
th
Year Elective Rotations
PART I – TO BE COMPLETED BY THE STUDENT
Name:
þÿ
Date of Birth:
SSN:
Phone:
þÿ
þÿ
þÿ
Street Address:
þÿ
City:
State:
Zip:
þÿ
þÿ
þÿ
Student
Today's Date:
þÿ
Signature:
PART II- TO BE COMPLETED AND SIGNED BY A LICENSED PHYSICIAN, NURSE OR SCHOOL OFFICIAL
TB Skin Test (Mantoux): Most recent annual test date, or two step testing- most recent test must be within 12 months of
rotation start date.
Date Placed:
Date Read:
Results:
POS
þÿ
þÿ
NEG
Date Placed:
Date Read:
Results:
POS
þÿ
þÿ
NEG
If above test positive, please fill out the History of Positive TB Test (page 2 of this form)in addition to this page. Please
bring any records you have pertaining to the positive skin test (chest x-ray report, documentation from the physician
regarding the treatment received after the positive test and medication therapy).
Annual Flu Vaccine
Date:
þÿ
Health Care Provider's Name:
þÿ
Health Care Provider's Address:
þÿ
Health Care Provider's Phone:
þÿ
Health Care Provider's Signature:
Important: Save the completed PDF form by going to File – Save As and naming this form
LastNameFirstNameDHImmunizationUpdate.pdf
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