Immunization/Serology Requirements - AAMC

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