Student Immunization Record for the OU COLLEGE OF MEDICINE
School of Community Medicine
Name ______SSN ______
Address ______Date of Birth ______
Phone ______
Please complete this form and return to Delene Wallace in the SCM Student Services Office, 4502 E. 41st Street, Room 1C54, Tulsa, OK 74135-2512.
Items 1 – 7 must be answered. There are no exceptions.
  1. Tuberculin PPD Mantoux Skin Test (Tine or Monovac test not acceptable) complete items a or b i, ii or iii
a.Attach evidence of a negative tuberculin PPD (Mantoux) test received in the last 12 months. Test Date______
or
b.Attach evidence of a positive tuberculin PPD (Mantoux) test...... Test Date______
  1. Attach evidence of a follow-up negative chest x-ray received in the past ten years. . . .X-Ray Date______
  2. Attach evidence of a follow-up physical examination within last 12 months...... Specify Date______
  3. Did you receive isoniazid-based therapy?  No  Yes . Attach evidence of dates of therapy______to______

2. Tetanus and Diphtheria complete items a or b
  1. Attach evidence of three childhood Tetanus-Pertussis-Diphtheria (DPT)1)______2)______3)______
Attach evidence of one adult Tetanus-diphtheria immunization ...... 1)______2)______

or

  1. Attach evidence of two adult Tetanus-diphtheria (Td) immunizations received no less than four weeks apart,
With at least one of these received in the last ten years ...... 1)______2)______
  1. Varicella (chickenpox) complete item a or b
a.Attach evidence of varicella blood test . . .  Immune  Not immune ...... Test Date______
If blood test establishes that you are not immune to chickenpox, Item b is required.
b.Attach evidence of two varicella immunizations received no less than four weeks apart.1)______2)______
4. Rubeolacomplete item a or b
  1. Attach evidence of two rubeola immunizations four weeks apart after the age of twelve months1)______2)______

or

  1. Attach evidence of a positive blood test ...... Test Date______

  1. Mumps complete item a or b
  1. Attach evidence of one mumps immunization received after the age of twelve months . . . . .Test Date______

or

b.Attach evidence of a positive blood test ...... Test Date______
  1. Rubella complete item a or b
  1. Attach evidence of one rubella immunization received after the age of twelve months . . . . .Test Date______

or

  1. Attach evidence of a positive blood test ...... Test Date______

  1. Hepatitis B Immunizations complete item a or b or c
  1.  I will complete the hepatitis B immunization series through the College when classes begin.

or

  1. Attach evidence of one, two, and three hepatitis B immunizations & dates1)______2)______3)______

or

c.Attach evidence of a positive blood test ...... Test Date______
If you do not have written evidence of the above immunizations, your physician or health care provider may complete and sign this form. However, you must support any claim of a blood test, chest x-ray, or physical examination by attaching a copy of the report.
Health Care Provider Name (Printed)______Signature______Date______
Address______Phone______