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Immunization & Student Responsibility Form


First Name*
Last Name*
700 Number (Student Number)*
Major*
Date of Birth*
Street Address*
City, State, Zip*
Phone Number*

Tetanus-Diphtheria-Acellular Pertussis - after the initial series, a booster is required every ten years, every five years if an injury occurs. Completed and updated consistent with schedule.

TDaP Date*

Measles, Mumps & Rubella (MMR) - consistent with University of Central Missouri Measles/Mumps/Rubella Policy. (Refer to policy in current University Planner/Handbook or the University Health Center web site). 2 vaccinations at least 28 days apart or serological proof of immunity (+) positive IgG titer for measles, mumps and rubella.

MMR Date
MMR Date
MMR Titer: Date, Results

Hepatitis B - a series of three injections over 6 months followed by post-series surface antibody titer 4-8 weeks after last vaccine is required.

Hepatitis B Date*
Hepatitis B Date*
Hepatitis B Date*
Hepatitis B Titer: Date, Results*

Tuberculin test – a 2 step method of tuberculin testing is performed. The initial ppd must be followed by another ppd between 1 – 3 weeks after reading. Must be completed on admission and annually (single step) thereafter.

TB screening: a TST within the past year: Date, Reaction
Chest X-ray for conversion or active TB within the past year: Date, Result
Completed treatment regimen for conversion or active TB: Date Completed, Medication

Chickenpox - 2 vaccinations at least 28 days apart or serological proof of immunity (+) positive IgG titer for varicella.

Varicella Date
Varicella Date
Varicella titer: Date, Results

Influenza - annually per CDC announced date (October 1 - March 31).

Influenza Date*

In terms of "Admission Requirements", I understand and agree to the following:


Verification of current and appropriate continuous updating of immunizations and CPR for health care providers.


Verification of my understanding of Confidentiality/HIPAA ~ all client/patient business observed or read while in a clinical setting to which I am assigned is considered confidential. I will not release or reveal information and records to which I have access. Questions regarding release of information will be referred to the health professionals in charge of the clinical settings.


Verification of "Admission Requirements" by paper may be required within 24 hours due to accreditation visits or audits. This includes immunizations, health insurance, CPR, criminal background check and drug screen if required by facility.


May be required by the clinical facility to provide a criminal background check and drug screen at my own expense.