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Penn State Healthrecord

This document outlines the immunization requirements that must be completed by visiting medical students prior to a rotation at Penn State College of Medicine. It requires proof of immunity through serology testing for hepatitis B, measles, mumps, rubella, and varicella. For hepatitis B, re-immunization is required if the titer is negative. Students must also provide documentation of vaccination or prior infection for varicella, tetanus/diphtheria/pertussis, and a recent tuberculin skin test unless previously positive.

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140 views1 page

Penn State Healthrecord

This document outlines the immunization requirements that must be completed by visiting medical students prior to a rotation at Penn State College of Medicine. It requires proof of immunity through serology testing for hepatitis B, measles, mumps, rubella, and varicella. For hepatitis B, re-immunization is required if the titer is negative. Students must also provide documentation of vaccination or prior infection for varicella, tetanus/diphtheria/pertussis, and a recent tuberculin skin test unless previously positive.

Uploaded by

wumaster9580
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

Immunization Requirements for Visiting Medical Students

Must be completed prior to rotation at Penn State College of Medicine


Print Name ____________________________________________ Date of Birth
Proof of immunity by serology. Attach copies of the laboratory reports.
Titer

Date of Titer

Result of Titer

If not immune, give


re-immunization date
2nd
3rd

Hepatitis B IgG quantitative*


1st
Rubeola Antibody IgG
Mumps Antibody IgG
Rubella Antibody IgG
Varicella Antibody IgG for
students with a history of
chickenpox.
* If Hepatitis B titer is negative re-immunization with a 3 dose series and a re-titer is
required.
Hepatitis B Status. Complete A or B.
A. Immunization Series. List dates of injection.
1ST Dose

2nd Dose

3rd Dose

B. If you had a prior hepatitis B infection, list the date and results of
hepatitis B surface antigen testing.
Result
Date
Varicella: Provider documented date of disease or 2 doses of vaccine.
Date of Disease
Immunization Dates
1st dose date
2nd dose date
Tetanus-diphtheria and acellualar pertussis note: Tdap, given as a booster if not received previously. An interval as short as 2 years since the most recent DT, 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 the student is known to have a previous significant (positive)
skin test. Note: a chest X-ray must follow a new positive tuberculin skin test.
Date Placed

By Signature

Date Read

Print Name

Result (in mm
Induration)

Address

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


Date of last chest X-ray
Report of last chest X-ray

Dean or Designees Signature


Revised 01/08/08

Date

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