Guest Student Required Immunizations
Form
It is imperative that you have certain
immunizations completed prior to your participation in our Guest
Student Senior Elective Program because of the direct patient
contact you will encounter during your professional training. The
appropriate information should be properly recorded by your
physician, or by your School. You may use the immunization sheet
provided or a signed copy of your school record. If using your school
record, please highlight and identify required information. This must be
sent with your application.
- TETANUS AND DIPHTHERIA - All
students must be immunized. (Must be with the last 10
years.)
- RUBELLA - All students are required
to have either a RUBELLA TITRE or receive RUBELLA
VACCINE. (the current standard at Indiana University
School of Medicine is that rubella immunizations is
required if the titre indicates susceptibility - lack of
detectable antibody.)
- RUBEOLA (Measles) - All persons
born after 1957 who have not had physician diagnosed
measles (rubeola) must show evidence of inoculation with
live virus measles vaccine on or after their first
birthday or show laboratory evidence of immunity. If
measles vaccine was received before 1968 and the type of
vaccine is unknown, evidence of vaccination after 1968
must be shown or immunity proven by laboratory testing.
- MUMPS - Male students are required
to be immunized if there is no definite knowledge of
having had the disease.
- POLIOMYELITIS - If you have NOT
previously been immunized for POLIO, please discuss this
with your physician and proceed according to this
instructions. Inactivated (Salk) vaccine is recommended
for adult immunization.
- TUBERCULOSIS - ALL STUDENTS MUST HAVE A
PPD TUBERCULIN SKIN TEST WITHIN THE LAST YEAR. If you
have a newly positive reaction to the skin test, a chest
x-ray is required and the results recorded on the
immunization sheet. Your physician should indicate what
treatment, if any, has been prescribed for you as a
result of a positive skin test or chest x-ray.
- HEPATITIS B IMMUNIZATION - is
required. Because of your contact with patients you will
be at increased risk for acquiring hepatitis B compared
to an individual not working in a health related field.
Hepatitis B may be prevented by immunization with the
hepatitis B vaccine. This vaccine is effective for
preventing infection and experience acquired in the
several years since its widespread use has indicated that
it is safe and well tolerated. Each student is encouraged
to ask his physician all questions pertaining to the
indicati ons, effectiveness and safety of the vaccine.
NAME___________________________________________________ DATE
OF BIRTH_______________
REQUIRED IMMUNIZATIONS AND
TESTS:
TB SKIN TEST (PPD) Date_____________Results:
Pos_____Neg_____
(UPDATE REQUIRED IF THIS TEST IS MORE THAN ONE YEAR OLD AT START OF ELECTIVE)
Chest Film (If Positive)
Date______________Treatment Prescribed (if any)_______________
TETANUS/DIPHTHERIA: (Within
last 10 years) Date of Last Booster:___________________
RUBELLA: Date and Titre
Reading:______________________________________________
Date of Vaccine if
Needed:_____________________________________________________
MUMPS: Date of Vaccine if
Given:_______________________________________________
MEASLES: Date Vaccine
Given:_________________________________________________
POLIO VACCINE: Date of
Series: OPV___________________________________________
Completed
Salk_____________________________________________________________
HEPATITIS B: Date Vaccine
Given:_____________________________________________
*PHYSICIAN SIGNATURE:________________________________DATE:______________ *May also be
signed by school official.