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UTHealth Student Health Services 6410 Fannin Street, Suite 1010 (In the UT Professional Building) Telephone: 713-500-5171 Fax: 713-500-0605 CERTIFICATION OF IMMUNIZATION

Please return this form to UTHealth Student Health Services in person or at the fax number noted above. Do not send it to the Registrar's Office and DO NOT MAIL FORM. You will be approved to register only after you satisfy all immunization requirements. Immunization requirements may vary by School. Please refer to the attached table to determine your specific requirements. Please have your health care provider complete this certification of immunization. If you are a prospective or current student at UTHealth and need immunizations, you are welcome to use Student Health Services ­ no appointment is required (8:30 a.m. to 5:00 p.m., Monday through Friday). Please contact our clinic for current vaccination prices.

___________________________________________

Last Name, First Name

_____________

Date of Birth

______________________

Social Security #

Current Address: _______________________________________________________________

Street & Apt. #

_______________________________________________________________

City, State Zip Code Country

Telephone (______) _________________ Alternate Telephone # (_____)________________________

Please check which school(s) you will be attending: ( ) GSBS ( ) Medical ( ) Dental ( ) Nursing ( ) Biomedical Informatics ( ) Public Health

____________________________ NAME

______________________ DOB

REQUIRED IMMUNIZATIONS___________________DATE ( month/day/year)

1.Tetanus/diphtheria or Tetanus diphtheria and Pertussis (Within last 10 years) 2. Measles (rubeola) vaccine: (2 are required if born after January 1, 1957) or Positive rubeola titer (attach lab report) 3. Mumps vaccine or Positive mumps titer (attach lab report) 4. Rubella vaccine or Positive rubella titer (attach lab report) 5. Hepatitis B vaccine series (3 injections) __________________________

#1 __________________________ #2 __________________________ __________________________

___________________________ ___________________________

#1___________________________ #2___________________________ #3___________________________

OR Positive Hepatitis B surface antibody titer (attach lab report) 6. Varicella vaccine series (2 injections)

___________________________ #1___________________________

#2___________________________ OR Chicken pox disease (documented by health care provider) or Positive varicella titer (attach lab report) ___________________________ 7. Bacterial Meningitis (Meningococcal) vaccine** (Within past 5 years)

____________________________

8. Tuberculin skin test (PPD) required within the last 12 months, even if you received BCG vaccine as a child.

Date:_________ Result:______ negative______positive (measurement_________ mm if available) If positive, did you take INH prophylaxis? _____ Yes ____ No Chest x-ray findings if PPD is positive (attach x-ray report) Date of chest x-ray: _______________

Health Care Provider Printed Name and Signature Address Phone Number City State Fax Number

License No. Zip Code

REQUIRED IMMUNIZATIONS

Tetanus/Diphtheria or Tetanus Diphtheria and Pertussis Measles (Rubeola)

MINIMUM REQUIREMENT

One dose within the past 10 years Two (2) doses of measles vaccine if born after January 1, 1957 administered on or after your first birthday and at least 30 days apart; or lab report of positive rubeola titer One dose of mumps vaccine administered on or after first birthday; or lab report of positive mumps titer One dose of rubella vaccine administered on or after first birthday; or immunity to rubella by presenting a lab report of positive rubella titer Within the past 12 months, even for those who have received BCG vaccine as a child. If PPD skin test is positive, a chest x-ray documenting no active tuberculosis must be submitted with immunization form Three-dose series (second dose one month and third dose six months after first dose) or lab report of positive hepatitis surface antibody titer. Must be vaccinated to most current status possible prior to registering for classes. Required of all incoming and transfer students 30 years old and younger. Students must have been immunized within the past 5 years and submit proof of immunization at least 10 days prior to the first day of class. Two-dose series (second dose one month after first dose) or a physician-validated history of the disease or lab report of positive varicella titer.

Mumps German Measles (Rubella)

PPD (TB) Skin Test

Hepatitis B Series

**Meningococcal (Meningitis)

Varicella (Chickenpox) Series

IMMUNIZATION REQUIREMENTS FOR EACH UTHealth SCHOOL

Measles Mumps Rubella Hepatitis B R R R R R R TetanusDiphtheria or TdaP R R R R R R PPD Meningococcal ** R R R R R R Varicella

School of Biomedical Informatics Dental School Nursing School Medical School GSBS School of Public Health Key: R=Required

R R R R R R

R R R R R R

R R R R R R

R R R R R R

R R R R R R

**Important information regarding the Meningococcal Vaccine**

Beginning with the Spring 2012 semester, Texas law (Education Code §51.9192, legislation attached) mandates that Texas universities and health science centers require all new and transfer students show proof of vaccination against bacterial meningitis. The law does not apply to new and transfers students who are over the age of thirty at the time of enrollment or who are enrolled only in distance learning classes. The only exceptions permitted by the law are for: 1) Students who can provide proof that a health care provider has determined that it would be a health risk for the student to have the vaccine; or 2) Students who use the Exemption Form issued by the Texas Department of State Health. Obtaining the required form from the Texas Department of Health Services to establish an exemption for reasons of conscience is a time-intensive process that usually takes about a month. If you are anticipating using this exemption then you will need to start this process early. This form can be requested at http://webds.dshs.state.tx.us/immco/affidavit.shtm .

*Please note if you are a student who previously attended our institution or another institution of higher learning before January 1, 2012 and are re enrolling following a break in enrollment of at least one fall or spring semester you must fulfill the meningitis vaccine requirement.*

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