Tufts University School of Medicine
Visiting Student Immunization Record Form

Name _________________________________________________________________________________     Birth Date _______ /_______ / ________

Last

 First    

Address____________________________________________________________________________________________________________________________

Street
City
State

    ZipCode

Country_______________________________                        USA Social Security # _______-______-________


Phone # ______________________________                          Exp. Grad. Year: ___________

(MM/YY)                                                          


RETURN THE COMPLETED FORM TO:

Clerkship Coordinator
School of Medicine
145 Harrison Avenue
Boston, MA 02111 USA
SAHA OFFICE USE ONLY
___________________________________
___________________________________
___________________________________
___________________________________

VACCINES        *See Requirements

MONTH/DAY/YEAR

Tetanus-Diphtheria Booster
  Received within past 10 years

 

_____/_____/_____

Measles/Mumps/Rubella (MMR)
  Two doses required

    Or, if given separately:
    Measles (2 doses) Live virus only
        or Positive Antibody Titer

    Mumps     or Positive Antibody Titer

    Rubella     or Positive Antibody Titer

  or vaccination within the
  past three years

Dose 1 _____/_____/_____   Dose 2 _____/_____/_____(MMR)

Dose 1 _____/_____/_____   Dose 2 _____/_____/_____(Measles)

                                    or +Titer _____/_____/_____x

Dose 1 _____/_____/_____    or +Titer _____/_____/_____

Dose 1 _____/_____/_____    or +Titer _____/_____/_____

Hepatitis B
   or Positive Antibody Titer (anti-HBs) 		Dose 1_____/_____/_____      Dose 2 _____/_____/_____

Dose 3 _____/_____/_____ or + Titer _____/_____/_____

Tuberculosis Test (Mantoux)
     Within the past 6 months    Date _________

Chest X-ray
   Required if TB Positive within the
   past year
     Had BCG Vaccine: ____ Yes ____ No

     INH Treatment: ____ Yes ____ No


Circle Result: Negative     Positive          Date _____/_____/_____

X-ray Result: Negative    Positive           Date _____/_____/_____

Length of Treatment:
   From _____/_____/_____ to _____/_____/_____

Varicella (Chicken pox)

(Bay State Medical Center requires a positive antibody titer, or two doses of vaccine)
        or Positive Antibody Titer

Had Disease Yes ____ No _____ Unknown _____

Dose 1 _____/_____/_____ Dose 2 _____/_____/_____

or + Titer _____/_____/_____

Polio Date of last booster

Last dose _____/_____/_____

                         

REQUIRED: ____________________________________________________________________________________________
  Physician’s Name (print)                             Physician's Address                                  Phone Number
  ___________________________________________________________________________      _____________
 

 Physician’s Signature                                                                                             Date


FD 3/00

 

State Immunization Requirements

In compliance with Massachusetts Law (105 CMR 220.600) and Tufts University policy, students must present a physician’s certificate showing documentation for the following immunization prior to arrival.

1. Tetanus-Diphtheria: An adult booster given within the past ten years.
2.  Measles: Two doses of live virus vaccine given at least one month apart, beginning at or after 12 months of age. Measles vaccine prior to 1968 is acceptable only if live vaccine was given.
3. Mumps: At least one dose of each vaccine given at or after 12 months of age.
4. Rubella: At least one dose of each vaccine given at or after 12 months of age.
5. Hepatitis B (Recombivax-B): Vaccination or laboratory evidence of immunity (positive anti-HBs titer), unless medically contraindicated. Vaccination protocol: a series of three injections given at intervals of 1, 2, and 6 months. (Testing for immunity to Hepatitis B after vaccination is strongly recommended. It is estimated that 10% of those given the initial series will not develop an adequate antibody response. Additional doses may be needed to develop immunity.)

The above requirements shall not apply where:

1. The student meets the standards for medical or religious exemption set forth in M.G.L. c.76, 5.15c;
 2. The student provides a copy of an immunization record from a school in the Commonwealth of Massachusetts indicating receipt of the required immunizations; or
3. In the case of measles, mumps, rubella, or hepatitis B, the student presents laboratory evidence of immunity.

Additional University Requirements

1.Tuberculosis Test: All visiting students, who are not known to be tuberculin positive, are required to have a tuberculosis test (Mantoux) within the six  months prior to arrival at Tufts University. Any student with a positive tuberculosis test must submit documentation of a chest X-ray taken within  one year prior to arrival.

  Students who are already known to be tuberculin positive from an exposure must submit documentation of: a tuberculosis test; INH treatment; and a  chest X-ray received within one year prior to arrival. A history of BCG vaccine is not acceptable as proof of being tuberculin positive. You must  provide documentation of a past, positive tuberculosis test, in addition to a chest X-ray received within one year prior to arrival.

2. Rubella: All students must present laboratory evidence of immunity (positive antibody titer).

3. Varicella (Chicken pox): Verification of history of disease, or laboratory evidence of immunity (positive antibody titer); or two doses of vaccine given  4 to 8 weeks apart. Bay State Medical Center does not accept history of disease as criterion for immunity.

Additional Recommendations

1. Polio Vaccine: Students should have received the polio vaccine along with the DPT series as a child. If so, nothing further is necessary. If not, please ask your physician about recent changes regarding adult polio vaccination.

2. Influenza Vaccine: Annual vaccination is recommended for health care workers who have patient contact.

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