MIDWESTERN UNIVERSITYGlendale Campus Office of Student Services 19555 North 59 th Avenue Glendale, AZ 85308 623/572-3210 Certificate of Immunity Form To be completed by health care prov
Trang 1MIDWESTERN UNIVERSITY
Glendale Campus Office of Student Services
19555 North 59 th Avenue Glendale, AZ 85308 623/572-3210
Certificate of Immunity Form
To be completed by health care provider.
Name: _ Program: _ Student ID#: Date of Birth: _
1 MEASLES (Rubeola)
Two immunizations with live virus vaccine
1st: _ 2nd: _
(month-day-year) (month-day-year)
Immunity confirmed by blood titer (valid only with copy of lab report)
Date of test: _ (month-day-year)
2 RUBELLA (German Measles)
One immunization with live virus vaccine
(month-day-year)
Immunity confirmed by blood titer (valid only with copy of lab report)
Date of test: (month-day-year)
3 MUMPS
One immunization with live virus vaccine
(month-day-year)
Immunity confirmed by blood titer (valid only with copy of lab report)
Date of test: (month-day-year)
4 TETANUS/DIPHTHERIA (DTP, DT, Td)
One immunization (Td) - (must have been received within the last 10 years)
NO TITER REQUIRED
Date of immunization: _ (month-day-year)
(See back page)
Rev 1/30/07
Trang 25 HEPATITIS B — ANTIBODY
Three doses of Hepatitis B vaccine A blood titer is also required 30 days after the 3rd immunization to prove
immunity
1st: _ 2nd: _ 3rd: _
(month-day-year) (month-day-year) (month-day-year)
Immunity confirmed by Hep B Surface Antibody titer (valid only with copy of lab report)
Date of test: (month-day-year)
6 TWO-STEP TUBERCULOSIS (TB) SKIN TEST
-Each student will need to have an initial two-step baseline TB test (A two-step TB test requires two separate
injections and two separate readings) Annual one-step skin tests are required by Midwestern University after an initial two-step baseline TB test If you have tested TB positive before, we will need annual verification from a physician that you do not have active tuberculosis or a clear chest x-ray
Date of TB test #1 : (month-day-year)
Results:
Date of TB test #2: (month-day-year)
Results:
7 VARICELLA (Chicken Pox)
-Immunity confirmed by blood titer (valid only with copy of lab report)
Date of test: _ (month-day-year)
HEALTH CARE PROVIDER CERTIFICATION AND INFORMATION
Name (Print): Credentials / Title: Signature: _ Telephone #: ( ) Fax: ( ) _
Physician/Healthcare provider: For questions please contact Midwestern University Student Services at
623/572-3210.
Please return all documentation to:
MIDWESTERN UNIVERSITY • ATTN: Student Services
19555 North 59th Avenue • Glendale, AZ 85308 • 623/572-3210
I authorize Midwestern University to release this immunization record to external rotation (clerkship) sites, preceptors, and/or to the Arizona Department of Public Health, or its designated representative, for compliance audits and in the event
of a health or safety emergency
Student’s Signature _ Date _
Rev 1/30/07