Immunizations - University of Illinois at Chicago

U I C College of Pharmacy
MANDATORY PHARMACY STUDENT IMMUNIZATION DOCUMENTATION FORM
DOB:
Student Name:
UIN # (I-card or admissions letter)
e-mail address:
CAMPUS: ¨ Chicago ¨ Rockford (Circle one) P1 P2 P3 P4 Class of:_________ University of Illinois College of Pharmacy Immunization Requirements
TUBERCULOSIS ¨ Has had the disease ¨ Has NOT had the disease
(complete one option below)
TB MUST BE DONE ANNUALLY
2 Step Tuberculin Skin Test (TST)
TST Step 1 Date read ________ Result _____mm induration
(readings must be done 48 hours after application)
TST Step 2 Date read ________ Result _____mm induration
OR
¨ QTBG Quantiferon-Gold Blood Test on Date: ______________ Results____________
OR
¨ Had a positive Mantoux skin test on Date: ______________ with Baseline Chest x-ray Date: __________ Result: POS - NEG OR
¨ Had BCG vaccine on Date: _______________
MEASLES (Rubeola)
¨ Titer drawn on Date: ______ Results: POS – NEG
If negative, date of re-immunization*: ___________ (Titer required 4-6 weeks post re-immunization to confer immunity.)
MUMPS
¨ Titer drawn on Date: ______ Results: POS – NEG
If negative, date of re-immunization*: ___________ (Titer required 4-6 weeks post re-immunization to confer immunity.)
GERMAN MEASLES (Rubella) ¨ Titer drawn on Date: ______ Results: POS – NEG
If negative, date of re-immunization*: ___________ (Titer required 4-6 weeks post re-immunization to confer immunity.)
TETANUS, DIPHTHERIA, and PERTUSSIS Three primary series immunizations are needed. (Please fill in relevant portion below.)
¨ Immunization 1 Date: ________ ¨ Immunization 2 Date: _________ ¨ Immunization 3 Date: _________ AND
¨ Last Booster Shot - Date: ________ Type – TdaP (required) (booster must be within last 10 years)
POLIO Three Immunizations are needed OR date of last booster OR date of immunization as an adult. (Please fill in relevant portion below.)
¨ Immunization 1 Date: ________ ¨ Immunization 2 Date: _________ ¨ Immunization 3 Date: _________ OR
¨ Last Booster Shot - Date: ________ ¨ Oral (Sabin) ¨ Injection (Salk)
OR
¨ Immunized as an Adult Date Conferred: _________
HEPATITIS B Three immunizations needed AND titer drawn to prove immunity. (Please fill in relevant portion below.)
¨ Immunization 1 Date: ________ ¨ Immunization 2 Date: _________ ¨ Immunization 3 Date: _________
¨
¨ Titer drawn
Date: ______
HB surface antigen POS – NEG HB surface antibody POS – NEG
(Antibody must be positive; if antibody titer is negative, the antigen is required.)
Date : ______ Results POS – NEG Date of Re-immunization: ___________
VARICELLA ZOSTER (Chicken Pox) ¨ Titer drawn
¨ Booster shot Date: _________
¨ Booster shot Date: _________
INFLUENZA (Seasonal)
INFLUENZA MUST BE DONE ANNUALLY prior to November 1st
Date:________ OR DECLINED because:_____________ (please note that declination will restrict IPPE/APPE site placement)
**COPIES OF LAB REPORTS SUPPORTING INFORMATION AND TITERS ABOVE MUST BE ATTACHED**
*Titers must be reported as quantitative results*
CERTIFICATION by Health Care Professional
Name of Health Care Provider Filling out Form:
RN
MD DO APN
Name and address of Institution or Clinic (or stamp)
Phone:
FAX:
I certify that this information is complete and correct to the best of my knowledge. Copies of lab report are attached as requested above.
X__________________________________________________________
Signature of Health Care Provider
Date: _____________________
st
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Æ Completed Form Must Be Received by College of Pharmacy by AUGUST 1 EACH yearÅ
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Å Applicant: Return ORIGINAL FORM (with attached documentation) to: Chicago Campus: Rockford Campus: University of Illinois at Chicago -‐ College of Pharmacy Office of Experiential Education Attention: Ms. Jennifer Dietrich 833 South Wood Street, Room 164 Chicago, IL 60612-‐7230 Phone: 312-‐996-‐6300 E-‐mail: [email protected] University of Illinois at Rockford -‐ College of Pharmacy Office of Experiential Education Attention: Ms. Rhonda Larkin 1601 Parkview Avenue, Room A314 Rockford, IL 61107 Phone: 815-‐395-‐5661 E-‐mail: [email protected] -----NOTE: YOU ARE REQUIRED TO RETAIN COPIES for YOUR PERSONAL FILES-----

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