Community College

PRINCE GEORGE'S

COMMUNITY COLLEGE

PHLEBOTOMY TECHNICIAN

Health Assessment Form

Workforce Development and

Continuing Education

Student ID No. Date

(Mr.)

(Mrs.)

(Ms.)________________________________________________________________________________________________________

Name (Last) (First) (Date of Birth)

Phone (Home) (Work)

Street Address

City State Zip Code

HEALTH CENTER, PRINCE GEORGE’S COMMUNITY COLLEGE

301 Largo Road, Bladen Hall, Room 132, Largo, MD 20774

(301) 546-0845

Laboratory Studies and Immunization Status (Please indicate result or action and date)

1. Hepatitis Vaccine (Required)

Hepatitis B Antibody Titer

Dates of Hepatitis Vaccines:

#1____/____/____

#2____/____/____

#3____/____/____

2. Measles, Mumps, Rubella (MMR) Immunization

Titers indicating immunity will be accepted in lieu of MMR immunization.

NOTE: If born before 1957, you are considered immune to Measles, Mumps and Rubella. However, titers indicating immunity is required (CDC).

After 1969 and after 12 months of age:

a. Measles/MMR—Two Measles (or MMR) immunizations are required. Received after 1st birthday.

#1 / / #2 / /

b. Rubeola (Measles) Titer: ____/____/____

immune ÿ non-immune ÿ

Measles immunization: ____/____/____

c. Mumps Titer: ____/____/____/

immune ÿ non-immune ÿ

Mumps immunization: ____/____/____

d. Rubella (German Measles) Titer:

____/____/____

immune ÿ non-immune ÿ

Rubella immunization: ____/____/____

*3. TB Test (Mantoux PPD): ____mm in duration

Due yearly

a. PPD Planted ____/____/____

PPD Read ____/____/____

b. CXR (required for current positive reaction)

normal ÿ abnormal ÿ Date __________

NOTE: A history of positive PPD skin test requires

a. Documented Negative CXR

Date_________________

b. Annual Review of TB Symptoms by health care provider positive ÿ

negative ÿ

Date______________

4. Varicella: (Chicken Pox)

Varicella Titer:

immune ÿ non-immune ÿ ____/____/____

Varicella Immunization #1 ____/____/____

#2 ____/____/____

5. Tetanus/Diphtheria (required within last 10 years)

Date of last booster: ____/____/____

6. Influenza shot Date____/____/____

*Available free of charge at Health Center, Bladen Hall, Room 132; call 301-322-0845 for appointment

This student is cleared on the basis of the personal history, immunizations, and laboratory test results to participate in clinical laboratory experience.

____________________________________________________ _____________________________________

(Examiner’s signature) (Date)

____________________________________________________ _____________________________________ (Type or print physician’s/practitioner’s name) (Office telephone)