Download Host`s Immunization Form

Student Name: __________________________________________________Date of Birth_________
Last First MM/DD/YYYY
DOCUMENTATION OF IMMUNIZATION REQUIREMENTS
(To be completed by Health Care Provider (HCP) or School Official)
Information for HCPs or School Officials completing this form:
Documentation of Immunity (AS DEFINED ON THIS FORM) to each of the following diseases is REQUIRED. Your
signature and credentials are requested at the end of this form.
All sections must be completed for school acceptance.
DO NOT SEND IMMUNIZATION RECORDS.
1. MEASLES (RUBEOLA): Two doses of measles-containing vaccine on or after 12 months of age AND a positive IgG
antibody titer.
#1___/___/____ #2___/___/___
Date of positive titer: ___/____/____
Date of booster if negative titer: ____/___/___
2. MUMPS: Two doses of mumps-containing vaccine on or after 12 months of age AND a positive IgG antibody
titer.
#1___/___/____ #2___/___/___
Date of positive titer: ___/____/____
Date of booster if negative titer: ____/___/___
3. RUBELLA: One dose of rubella-containing vaccine on or after 12 months of age AND a positive titer.
#1___/___/____
Date of positive titer: ___/____/____
Date of booster if negative titer: ____/___/___
4. Tdap: One dose of Tdap since age 16 years or within last 10 years.
Date: ___/___/____
5. SEASONAL INFLUENZA: One dose of seasonal flu vaccine required annually.
Date:___/___/____
Student Name: __________________________________________________Date of Birth_________
Last First MM/DD/YYYY
6. VARICELLA: Two doses of varicella-containing vaccine on or after 12 months of age AND a positive IgG antibody
titer.
#1___/___/____ #2___/___/___
Date of positive titer: ___/____/____
Date of booster if negative titer: ____/___/___
7. HEPATITIS B: Three doses of vaccine AND a positive Hepatitis B Surface Antibody (HepBsAb) titer.
#1___/___/____ #2___/___/___ #3___/___/___
Date of positive titer: ___/____/____
Date of booster(s) or repeat series if negative titer:
#4____/___/___ #5___/___/___ #6___/___/___
Date of repeat titer: ___/___/___ Positive? Yes___ No____
NOTE: Hepatitis B Non-Responders have a negative HBsAb after 2 documented 3-dose series of Hepatitis B vaccine.
Non-responders must submit proof of counseling with a health professional to discuss their status and implications
(such as immunizations necessary at time of blood borne pathogen exposure and need for rigorous adherence to
standard precautions.)
Those with Hepatitis B disease must submit evidence that they are being followed by an infectious disease
specialist and have received counseling regarding protection of patients.
8. TUBERCULOSIS: One negative PPD screen in the past 12 months or negative IGRA.
Date: ___/____/___ Size (mm):__________
Date of Negative IGRA___/___/___
FOR POSITIVE PPD OR IGRA ONLY:
Date of CXR:___/___/____ Result:_________(attach report)
Student received counseling for latent TB infection: Date___/___/___
Student took INH: Date:___/___/___ to ___/___/___
Student is currently free of symptoms: Yes___ No___
HEALTH CARE PROVIDER OR SCHOOL OFFICIAL INFORMATION
HCP or School Official’s Name____________________________________ Title______________
Name of School_________________________________________________________________
Address_______________________________________________________________________
Phone_________________________Email___________________________________________
Signature______________________________________________________________________