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    KSU Immunization Form 2016

    Uploaded by

    Amin
    This document is a mandatory student immunization form for Kent State University. It requires students to provide information about their measles, mumps and rubella vaccinations as well as tuberculosis screening for international students. The form must be completed and signed by a healthcare provider to verify immunization dates.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    KSU Immunization Form 2016

    Uploaded by

    Amin
    31 views1 page
    This document is a mandatory student immunization form for Kent State University. It requires students to provide information about their measles, mumps and rubella vaccinations as well as tuberculosis screening for international students. The form must be completed and signed by a healthcare provider to verify immunization dates.

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    KSU Immunization Form 2016

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    This document is a mandatory student immunization form for Kent State University. It requires students to provide information about their measles, mumps and rubella vaccinations as well as tuberculosis screening for international students. The form must be completed and signed by a healthcare provider to verify immunization dates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    31 views1 page

    KSU Immunization Form 2016

    Uploaded by

    Amin
    This document is a mandatory student immunization form for Kent State University. It requires students to provide information about their measles, mumps and rubella vaccinations as well as tuberculosis screening for international students. The form must be completed and signed by a healthcare provider to verify immunization dates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    SUBMIT THIS FORM TO:

    Kent State University Health Services


    1500 Eastway Drive, Kent OH 44242-0001
    Phone (330) 672-8263 Fax (330) 672-2272 or Email: [email protected]

    Mandatory Student Immunization Requirements

    Last Name: ___________________________________First Name: _________________KSU ID# __________________


    Address _________________________________________________Cell Phone_______________________________
    City ________________________________ State ___________________________Zip _________________________
    Date of Birth ____________________ Birth Country _________________________ E-Mail _____________________

    Students born before Jan. 1 st, 1957 are exempt from Part I. All other students must complete and submit Part I
    International students must also complete Part II.
    PART I - MEASLES/MUMPS/RUBELLA (MMR VACCINE)

    Requirement: TWO doses of MMR vaccine after the age of one Date: #1 ___________________
    and separated by at least one month
    #2 ___________________
    -OR-
    If immunizations were NOT given in the MMR combined vaccine – please indicate dates received:

    Date: MEASLES #1 _______________ MUMPS #1 _______________ RUBELLA #1_______________


    MEASLES #2 _______________ MUMPS #2_______________ RUBELLA #2 _______________

    ALL IMMUNIZATION DATES MUST BE VERIFIED BY A PHYSICIAN OR HEALTH CARE PROVIDER


    -OR-
    A COPY OF YOUR IMMUNIZATION RECORD MUST BE ATTACHED TO THIS COMPLETED FORM

    Healthcare provider’s name and address:


    _____________________________________________ _______________________________________________________
    Healthcare Provider Signature
    _____________________________________________

    _____________________________________________

    PART II – TB SCREENING – INTERNATIONAL STUDENTS ONLY


    Students from the following countries are required to have tuberculosis screening: Africa, Eastern Europe, Russia, Mexico, Central America, South
    America, Asia, the Middle East, the Pacific Islands and the Caribbean. This test must be completed within 12 months prior to starting classes.
    (For a complete list of the World Health Organizations high risk countries visit World Health Organization Global Health Observatory)
    □ I was not born in or had an extended stay in any country listed above
    Tuberculosis Skin Test (Mantoux): Date Given: _______________Date Read :_________________Results Required (millimeters)______________

    If you previously received a BCG vaccine, a blood test such as Quantiferon Gold is the preferred test to indicate absence of TB.
    Date:__________________ Result (Check one) □ Positive □ Negative
    If a current or past TB screening or Quantiferon Gold Test was positive, you will need to complete the following:
    Chest X-ray date: ___________________ Result(Check one) □ Positive □ Negative
    Treatment: □ YES □ NO – Document drug/dose/frequency____________________ Date and length of treatment_________________________

    Document reason prophylaxis or treatment not done______________________________________________________________________________

    Healthcare Provider’s Name and Address:______________________________________________________________________________________

    Healthcare Provider’s Signature:______________________________________________________________________________________________


    Rev: 2016/8 sv

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