Immunization Record Form - American University Of Antigua

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Immunization Record Form
PART 1: To be completed by the student
Last Name:
First Name:
Date of Birth (mm/dd/yyyy):
Term of Admission:
PART 2: To be completed and signed by a health care provider.
Date (mm/dd/yyyy)
Details / Titer results and dates
Most recent PPD Date:
Tuberculosis Screening (PPD)
Result:
Must be taken within 12 mo. prior to
starting AUACOM third semester
If positive (MM induration and date of +)
CXR _____________________ Quantiferon Gold _____________________
Measles Titer
MMR #1
Measles / Mumps / Rubella
Mumps Titer
MMR #2
(MMR)
Rubella Titer
Any additional/booster MMR?
a. Primary series complete? (At least three dose dates are required)
Series 1
Series 2
Tetanus and Diphtheria
Series 3
(DT or DPT)
Tetanus toxoid (TT) is not acceptable
b. Most recent booster? Date: (Must be within the last 10 years)
c. Exemption?
Attach physician’s statement of medical contraindication with duration of medical condition or attach your personal statement of philosophical/religious objection to immunization.
Did you have disease? Fill in “x” [ ]YES
[ ]NO
Varicella #1
Varicella (Chicken Pox)
Varicella #2
Any additional/booster Varicella?
Hepatitis B #1
Hepatitis B #2
Hepatitis B
Hepatitis B #3
Any additional/booster Hep. B?
Health care provider verifying information for Part 2
Name:
Date (mm/dd/yyyy):
Signature:
Physician Details
Address:
FOR OFFICE USE ONLY
Date Received:
Manipal Education Americas, LLC Representative for
1 Battery Park Plaza
p: 1 (877) 666-9485
American University of Antigua
New York, NY 10004
f: 1 (973) 498-7707
Complete:

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