By Franklin R. Cole, Ph.D. - College of Pharmacy - Idaho State ...

Health Status Form
Name _____________________________
MEASLES
Born prior to 1957
OR
Documentation of physician diagnosed measles. (Attach copy)
OR
Laboratory evidence of measles. (Attach copy of laboratory results)
OR
Documented immunization with two doses of live virus vaccine on or after first birthday
given at least one month apart.
Date of 1st Dose ______________ Date of 2nd Dose _______________
MUMPS
Documentation of physician diagnosed mumps. (Attach copy)
OR
Documented immunization with one dose of live virus mumps vaccine on or after first
birthday. Date of immunization _____________________.
RUBELLA
Laboratory evidence of rubella immunity. (Attach copy of laboratory results).
OR
Documented immunization with one dose of live virus rubella vaccine on or after first
birthday. Date of immunization _____________________.
TB SKIN TEST
Date of negative PPD ___________OR Date of negative CXR_________________
Date of chest x-ray ____________________OR treatment _________________
CHICKEN POX (Varicella)
History of having Chicken Pox; either self-identified or written verification; ______.
OR
Immunization for Chicken pox Date of immunization ____________________
HEPATITIS B
Laboratory evidence of immunity (Attach copy of laboratory results)
OR
Documented immunization by completing the vaccine series.
Date of immunizations #1 _________, #2 ___________, #3 ___________
Signature of authorized health care provider
_________________________________
37 2006 College of Pharmacy Student Handbook