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Penn State Healthrecord

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Immunization Requir Requir ements ements for Visiting Medical Students Must be completed pri or to r otation at Penn State State College of Medicine Medicine Print Name  ____________________________________________Date Date of Birth Proof of immunity b y serology. Attach copies of the laboratory reports. Titer

Date of Titer

Result of Titer st

If not immu ne, give re-immunization re-immunization date nd rd 2 3

Hepatitis B IgG quant itative* 1 Rubeola Antibody IgG Mumps Antibod y IgG Rubella Antibody IgG Varicella Varicella Antibod y IgG for students with a history of chickenpox. * If Hepatitis Hepatitis B titer is negative re-immunization re-immunization with a 3 dose series and a re-titer re-titer is required. Hepatitis B Status. Complete A or B.  A. Imm un izat io n Series Ser ies . List Li st dat es o f i nj ect io n. ST

1

Dose

nd

2

rd

Dose

3  Dose

B. If you had a prior hepatitis B infection, infection, list the date and results of hepatitis B surface antigen testing. Result Date Varicella: Varicella: Provider docum ented date of disease or 2 doses o f vaccine. Date of Disease Immuni zation Dates st nd 1 dose date 2  dose date Tetanus-diphtheria Tetanus-diphtheria and and acellualar acellualar pertussis n ote: Tdap, Tdap, given as a booster if not received previously. An interval as short as 2 years since the mos t recent DT, DT, DtaP, DtaP, or Td should be used. Date: Tdap, DT or Td Tuberculin Status. An intradermal tuberculin skin test (5 TU-PPD) within the past SIX Months is required unless th e student is know n to have a previous signifi cant (positive) skin test. Note: a chest X-ray X-ray must fo llow a new pos itive tuberculin skin t est. Date Placed

By Signature

Date Read

Print Name

Result (in mm Induration)

 Address

If positive skin test, attach attach a copy of the last X-ray X-ray report. Date of last chest X-ray Report of last chest X-ray

Dean Dean or Designee’s Signatur e

Revised 01/08/08

Date

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