Immunization/Serology Requirements - AAMC

Immunization/Serology Requirements
The University of Vermont requires documentation of positive titers and current vaccinations prior to the start of classes.
THIS FORM MUST BE COMPLETELY FILLED OUT AND SIGNED. It is your responsibility to review your forms for
completeness.
Please forward the completed form and attached lab reports to the address below directly—do not have a physician or
health care professional do so for you. We also recommend keeping a copy of the completed form and accompanying
paperwork for your records.
This form must be uploaded to VSAS before your application will be reviewed.
Serology/immunization requirements are as follows:
1. TUBERCULOSIS CLEARANCE:
A Mantoux test must be administered by a licensed health care provider. You are required to have the two-step
method of testing done. The two-step requires placement of 2 separate PPD skin tests 7 to 14 days apart. If you
have a history of a positive TB skin test, you must submit a chest x-ray report, along with a physician’s report. BCG
vaccine does not preclude the need for PPD testing or chest x-ray.
2. TETANUS/DIPTHERIA/PERTUSSIS BOOSTER:
Your TD booster must have been administered within two years of the date of your proposed elective. So if you
received a TD booster in May of 2008, for instance, you’ll be covered until May of 2010. If you’ve had a Tdap
(Adacel is the brand name, and these weren’t available until late 2005), you will be covered for ten years from the
date of immunization.
3. MEASLES (Rubeola), MUMPS, RUBELLA (MMR), AND VARICELLA:
You must have your blood drawn to show proof of immunity to Measles, Mumps, Rubella (MMR), and Varicella,
even if there is a history of infection.
Lab tests required: Measles IgG, Mumps IgG, Rubella IgG, and Varicella IgG
Submitting proof of vaccine only is not acceptable. Important: All blood tests (titer results) must be provided as
copies of lab reports. Physician documentation as positive or negative alone will not suffice.
4. HEPATITIS B SERIES:
You are required to have a series of three doses of Hepatitis B vaccine and show proof of a positive Hepatitis Surface
Ab titer. Note: If you have not completed your Hepatitis B series, you may do so at Student Health Services.
5. POLIO:
List the dates of the four-shot childhood series. For adults who had 1 or 2 IPV doses, and no documentation of the
childhood series, they will need to complete a total of three injections. Therefore, if they received one injection,
they would need to receive an additional two adult catch-up injections.
*All negative or inconclusive titer results will require a booster and follow-up titer.
Immunization/Serology Records Form

LAB RESULTS ABSOLUTELY MUST BE ATTACHED FOR EVERY ITEM LISTED, AND ALL FIELDS
MUST BE COMPLETED WITH REQUESTED INFORMATION, OR ENTIRE FORM WILL BE REJECTED
Name: SSN or Passport ID #: DOB:
1. TB Screening:
#1 Date placed: ___________ Date read: ___________ Millimeters of Induration: __________
#2 Date placed: ___________ Date read: ___________ Millimeters of Induration: __________
Note: If you have a positive tuberculin skin test, you must submit the following:
Chest x-ray Date: ______________ Result: ______________
Treated with INH? Yes No Date started: __________ Date completed: ________
(BCG alone is not acceptable as a positive history.)
2. Tetanus, Diphtheria, Pertussis Booster (Tdap (Adacel) mandatory):
Two years from your last Td (longer if Tdap was given after late-2005)
□ lab report attached
Booster date: _____________
3. Measles, Mumps, Rubella, Varicella:
Negative or inconclusive titer results require booster.
Measles (Rubeola)
Titer date/result: ________________________ ________________________ □ lab report attached
Date booster administered
Mumps
Titer date/result: ________________________ ________________________ □ lab report attached
Date booster administered
Rubella
Titer date/result: ________________________ ________________________ □ lab report attached
Date booster administered
Varicella
Titer date/result: ________________________ #1_________ #2_________ □ lab report attached
Date booster administered
4. Hepatitis B Series:
Series #1 date: ____________ #2 date: ____________ #3 date: ____________
Hep B Surface Ab date/result: ________________
□ lab report attached
If you have not converted, repeat the series in attempt to gain immunity.
Series #4 date: ____________ #5 date: ____________ #6 date: ____________ □ lab report attached
Hep B Surface Ab date/result: ________________
Note: If the series has not been completed prior to matriculation, it may be completed at the Center for Health and
Wellbeing. Make your appointment several weeks in advance to ensure you meet the deadline, as the Center is very busy.
5. Polio:
#1: ___________ #2: ____________ #3: ____________ #4: ____________ □ documentation attached
By signing below, I affirm that I am a licensed health care provider. Further, I am aware that a failure to complete every field (items 1-5) and/or a failure to provide lab
results for all (items 1-5) will result in the student being unable to complete an elective at the UVM College of Medicine.
_________________________________________
Signature of Provider
________________________________________________
Print Name of Provider
_____________________
Date
_________________________
Provider telephone number