Immunization Record PART II: REQUIRED ITEMS. To be...
Transcript of Immunization Record PART II: REQUIRED ITEMS. To be...
Immunization Record PART I: To be completed by the student. Please print or type.
Last name First name MI RUID or A number Schoo l/Grad year/program
DOB (month day year) Cell phone number Email
PART II: REQUIRED ITEMS. To be completed and signed by health care provider. Date (mo day yr)
MMR (Measles, Mumps, Rubella), first dose after age 1 MMR Dose #1 MMR Dose #2 OR Measles (Rubeola) serologic immunity (attach lab report & list date of lab test) Mumps serologic immunity (attach lab report & list date of lab test) Rubella serologic immunity (attach lab report & list date of lab test)
Dose 1 __/__/__ Dose 2 __/__/__
__/__/__ Immune Non-immune__/__/__ Immune Non-immune
__/__/__ Immune Non-immune
Meningitis ACYW (required for ALL students under 19, first year college students in housing, those with risk factors1,2, and specific travelers3) with at least 1 dose since age 16
Meningitis B (required for students with risk factors1) 1asplenia, sickle cell, N meningitidis lab work, complement deficiency or complement inhibitor use 2HIV 3travelers to/residents of areas with endemic meningitis
__/__/__ Menveo Menactra Menomune __/__/__ Menveo Menactra Menomune__/__/__ Trumenba Bexsero __/__/__ Trumenba Bexsero __/__/__ Trumenba Bexsero
QUANTITATIVE Hepatitis B Surface Antibody Titer (qualitative will not be accepted per CDC guidelines). We recommend submitting a Hepatitis B Surface Antigen as well in case immunity is not demonstrated (attach lab reports)
Hepatitis B (if starting the series, at least 1 dose is required prior to enrollment)
__/__/__
__/__/__ Non-immune Immune (≥10 mIU/mL)
__/__/__ Dose 1 __/__/__ Dose 2 __/__/__ Dose 3
Hep B Surface Antigen Positive Negative
Tuberculosis - Two PPDs or an FDA approved blood test are required regardless of prior BCG within the past 12 months
PPD #1 (date placed __/__/__ ) OR PPD #2 (date placed __/__/__ ) FDA approved blood test for TB (eg. Quantiferon Gold) (attach report)
Date read
__/__/__ PPD#1
__/__/__ PPD#2
__/__/__
mm induration mm induration
Positive Negative
If PPD positive (≥10 mm), is the patient free of TB symptoms? Yes No List date of positive PPD and induration Was the student treated? Yes No For how long? FDA approved blood test for TB (Quantiferon Gold) (attach report) Chest x-ray required within the past 12 months if TB blood test is positive or not drawn (attach report)
__/__/__ _ mm induration
__/__/__ Positive Negative
__/__/__ Normal Findings:Adult Tdap (Tetanus, Diphtheria & Acellular Pertusis) (Adacel or Boostrix) __/__/__ Varicella (Chicken Pox)
Varicella Dose #1 Varicella Dose #2
OR Varicella serologic immunity (list date and attach lab report)
__/__/__ Dose 1
__/__/__ Dose 2
__/__/__ Immune Non-immuneAnnual flu (list vaccination for the current flu season)
Healthcare provider Address/Stamp/Phone/Fax
Print name
Signature Date
Engerix Heplisav TwinrixEngerix Heplisav TwinrixEngerix Heplisav Twinrix
Hep B Surface Antibody
Use your Rutgers login to upload this completed and signed form onto https://rutgers.medicatconnect.com/ Questions? email [email protected]
__/__/__
Immunization Record
Last name First name DOB (month day year) RUID or A number
PART III: Additional vaccinations: Please complete or attach a legible copy. We recommend submitting this information so we can better care for you at our health centers during your time at Rutgers.
Date (mo day yr)
Hepatitis A
Human Papilloma Virus
Japanese Encephalitis
Pneumococcal P CV13 P PSV23
Polio booster
Rabies vaccine
Typhoid TyphIM Vivotif (most recent dose)
Yellow Fever
Healthcare provider Print name Signature Date
__/__/____/__/__
__/__/____/__/____/__/__
P CV13 P PSV23 P CV13 P PSV23
P CV13 P PSV23
__/__/____/__/____/__/____/__/__
__/__/__ __/__/__
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__/__/____/__/____/__/__
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Use your Rutgers login to upload this completed and signed form onto https://rutgers.medicatconnect.com/ Questions? email [email protected]
Healthcare provider and student checklist (REQUIRED ITEMS)
Mandatory Health Form
□ Students must complete the ONLINE Mandatory Health Form athttps://rutgers.medicatconnect.com/
MMR
□ 2 doses of Measles, Mumps, and Rubella vaccine
OR□ MMR IgG titers showing immunity – attach lab report
LabCorp test #058495 Quest Diagnostic test #85803A
MeningitisACYW
MeningitisB
□ Meningitis ACYW (required for students under 19, first year college students in housing, those withasplenia, sickle cell, N meningitidis lab work, complement deficiency or complement inhibitor use, HIV,and travelers to/residents of areas with endemic meningitis)with at least 1 dose since age 16
Hep B
□ Hepatitis B Surface Antibody QUANTITATIVE titer (the result must be a number) attach labreport.LabCorp test # 006530 Quest Diagnostic test # 51938W
Please draw a Hepatitis B Surface Antigen as well since it will have to besubmitted if the student fails to demonstrate immunity.
□ Hepatitis B Surface Antigen - attach lab reportLabCorp test # 006510 Quest Diagnostic test # 265F
□ Please document all doses of Hepatitis B vaccine received on the immunization form
Options if a student is not immune: 1. Booster dose, followed by titers one month after, or2. Repeat the series, followed by titers one month after
PPD
□
OR □ an FDA approved blood test for TB (such as Quantiferon Gold)
LabCorp test # 182873 Quest Diagnostic test # 19453
Tdap □ Adult Tdap (tetanus/diphtheria/acellular pertussis) (Adacel/Boostrix) (one-time administration) afterage 19
Varicella □
2 doses of Varicella vaccine, at least 1 month apart OR
□ Varicella IgG titer showing immunity- attach lab reportLabCorp test # 096206 Quest Diagnostic test # 54031E
* Students working in healthcare with documented annual PPDs may submit that documentation to fulfill this requirement.Cat1 r4.10.20
Meningitis B (required for students with asplenia, sickle cell, N meningitidis lab work,complement deficiency or complement inhibitor use)□
These are CDC recommendations for all healthcare workers. The student will not be permittedto matriculate without these tests.
2-step PPD* (1-3 weeks apart) regardless of history of BCG• Please include date placed and date read in millimeters of induration• For a PPD ≥10 mm now or in the past, you must submit documentation
of the PPD reading and a chest x-ray report within the last 12 months
□Flu Annual flu (list vaccination for the current flu season)