IMMUNIZATION RECORD

 

 

Name:_________________________________________________________            DOB:____________________

 

**To be completed and signed by your health care provider**

1. MEASLES, MUMPS, RUBELLA:  Two immunizations for measles and one each for mumps and rubella are required.

The earliest the first immunization can be given is 12 months of age.

1st MMR: _____/______/_______

2nd MMR:_____/______/_______ OR Measles (Rubeola) ______/______/________

OR documented positive titer Measles (Rubeola) _____/_____ Mumps _____/______ Rubella _____/______

2.  HEPATITIS B completion of at least two of three required doses:

Dose 1______/______/______  Dose 2______/______/______  Dose 3______/______/______

3.  MENACTRA VACCINE  date:______/______/______

4.  TETANUS-DIPHTHERIA booster (must be within the last ten years) date: _____/______/______

5.  VARIVAX   history of disease (year) ________               OR  date of vaccine: ______/______/______

6.  POLIO  completed primary series of polio immunization yes ____ no _____ 

Date of last booster:  ______/______/______                     Type:  OPV _____ IPV ______ EP-IPV _______

7.  TB SCREENING within the year is required for students at high risk for TB as defined by the CDC (foreign born persons from high prevalence countries, persons with compromised immune systems, close contact with infectious TB cases)

TB skin test (PPD) Date______/______/______    Results __________________________________(mm induration)

If more than 5 mm, date and results of last chest x-ray (must be within one year)________/______/_________

If indicated, INH therapy________/_________/__________                      ___________/__________/_________

                                                      (date began)                                                                                date completed

HEALTH CARE PROVIDER

Printed Name______________________________      Signature______________________________________

Address______________________________________________________ Phone (______) _______________

 

 

STUDENT RELEASE:  I authorize Juniata College to release my immunization record upon my verbal request.  I understand release of all other information contained in my medical record will require my written authorization.

 

Student signature ____________________________________                 Date_________________________________