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Immunization Form & Confidentiality Statement

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

The Immunization Form is to be completed as part of the admission requirements. Some immunization requirements are ongoing and will need to be completed or updated while in the program. Although paper validation of the immunization history and CPR certification is not required, it is the responsibility of every student to demonstrate integrity in the reporting of this information.

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.

DT/TDaP Date*
DT/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).

MMR Date*
MMR Date*

Hepatitis B - a series of three injections are required.

Hepatitis B Date*
Hepatitis B Date*
Hepatitis B Date*

Tuberculin test – compliance with the facilities that the Department of Nursing utilizes, 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.

Two-step TB skin test within the past year: Date, Type, 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 - requirements may be met by 1 of 3 methods a) documented disease by doctor or physician, b) documented positive varicella titer (lab test), or c) documented varicella vaccine.

Documented disease by doctor or physician: Date
Varicella titer: Date, Results
Varicella vacine: Date

Persons who object to immunization due to religious or philosophical reasons or who have a health condition for not being able to receive immunizations will need to appeal to the Health Committee of the Department of Nursing in writing.

Statement of Confidentiality/HIPAA ~ I, a student, understand that all client/patient business observed or read while in a clinical setting to which I am assigned is considered confidential. I agree not to 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.

Submitting this form confirms you have the necessary immunization documentation and have read the Statement of Confidentiality/HIPAA and is acceptable in place of your signature.