Albert Einstein College of Medicine
Visiting Student Immunization Form
Completion of this form is required for every visiting student participating in an elective at Einstein. This form must be completed by a licensed physician, nurse practitioner or physician’s assistant.
VSAS Applicants: This form must be uploaded in VSAS under the appropriate document section prior to application review and elective registration. This form will not be accepted through fax or email.
Non-VSAS Applicants: This form must be included with the Einstein Visiting Student Elective Application prior to application review and elective registration.
Student’s Name: ______DOB (mm/dd/year): ______
Email: ______
A. Does this student have any acute or chronic health problems? If yes, Please explain:
______
______
______
B. Date of Last physical exam:______
Results of the exam: ______
______
______
C. Immunization Record
To be completed by licensed health professional
1. / Rubeola (Measles) / Titers date______/ □ Immune / Booster date______□ Non-Immune
2. / Rubella (German Measles) / Titers date______/ □ Immune / Booster date______
□ Non-Immune
3. / Mumps / Titers date______/ □ Immune / Booster date______
□ Non-Immune
4. / Varicella (Chicken Pox) / Titers date______/ □ Immune □ Non-Immune / 2 doses of vaccine 1 month apart required if negative titer:
Dose 1______
Dose 2______
5. / Tetanus (one dose in last 10 years) / Vaccine Date / □ Td □ Tdap
(note: Tdap is preferred and should be given if last Td over 2 years ago and no contraindication to vaccine)
Rev 1/2014
Student’s Name: ______DOB (mm/dd/year): ______
Immunization Record continued
To be completed by licensed health professional
6. / Hepatitis Bcomplete all items under 6a or have student sign declination under 6b
6a. Vaccine Dates / Dose 1______/ Dose 2______/ Dose 3______
Hep B Sab post vaccination titer (Quantitative) / Date______/ Value______/ Interpretation: □ Immune □ Non-Immune
HepBsAb Negative/equivocal only: / Hep B Surface Antigen / Date______/ □ Positive □ Negative
6b. Hepatitis B Vaccine Declination:
I understand that I may be at risk of acquiring a Hepatitis B virus infection. I have been given the
opportunity to be vaccinated with Hepatitis B vaccine, however, I decline vaccination at this time.
I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B.
Student's signature: ______
7. / Tuberculosis Screening
PPD Mantoux: Must provide two test results (if PPD negative) - one in the 12 months preceding
elective, and one in calendar year of elective. If PPD positive, provide date of first positive PPD
and provide CXR report, documentation of counseling and/or treatment for latent TB infection.
History of BCG is not a contraindication to testing.
PPD 1 (in 12 months prior to elective) / Date______/ Size (mm)_____ / □ Negative □ Positive (>10mm)
PPD 1 (in calendar year of elective) / Date______/ Size (mm)_____ / □ Negative □ Positive (>10mm)
For PPD Positive Only:
Chest X-ray / Date______/ Result (attach report) / □ Normal lungs □ Other findings
Student has been counseled regarding treatment for LTBI / □ Yes Date_____ / □ No
Student took INH / □ Yes Date_____ / □ No
Student is currently free of symptoms of TB / □ Yes / □ No
I have reviewed the immunization record and medical history, and examined the above named student on ______(date). The student is in good health, is free from evidence of communicable disease and does not pose a health risk to patients or employees at Albert Einstein College of Medicine, and their clinical affiliates.
______
Practitioner Name and title (print) Practitioner Signature
______
State and License Number Date form was completed
Office Address: ______
______
Telephone: ______Email: ______
Rev 1/2014
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