Health Record & Immunization Form

Health Record & Immunization Form (Student or Faculty) Name: Click here to enter text. Your designation : Choose an item. School: Click here to enter text.

Address: Click here to enter text. Contact #:Click here to enter text. Choose an item. Email Address: Click here to enter text. Date of Birth: Click here to enter text. Educational Program: Click here to enter text. Last 5 digits of SS # (Full SS# for USCSM students):Click here to enter text. School ID#:Click here to enter text.

Dates of Rotation: FromClick here to enter a date. to Click here to enter a date. GHS Employee: Choose an item. Status: Choose an item. Location:Click here to enter text. -Documented Proof of requirements must be immediately available to GHS Student Coordinator upon request. -Must submit supportive documentation for: “Positive” TB Screening, Hepatitis B declination, and Influenza exemptions -Form valid one (1) year from date signed-- Must be updated annually. -Immunizations are Mandatory for ALL Educational Affiliations with GHS. Please provide Vaccine dates and/or Titer dates for specified **immunizations** below: Immunization Vaccine(s) Date Titer Date Titer Result Date of Declination or Approved Exemption (attach copy) TB Screening (2-step PPD) “or” Annual PPD 2-Step PPD Annual PPDClick here to enter a date. NA NA NA #1Click here to enter a date. #2Click here to enter a date.

If “positive” tuberculin skin test: Baseline CXR Date (within 3 months):Click here to enter a date.______TB Evaluation Form Date:_Click here to enter a date. Acceptable Blood Tests: QuantiFERON®-TB test (QFT) Blood Test Date: Click here to enter a date.Results: Choose an item. T-SPOT®.TB Blood Test Date:Click here to enter a date. Results: Choose an item. Rubella** Click here to enter text. Click here to enter text. Choose an item. NA Rubeola** #1:Click here to enter text. #2:Click here to enter text. Click here to enter text. Choose an item. NA Mumps** #1:Click here to enter text. #2:Click here to enter text. Click here to enter text. Choose an item. NA *GHS accepts documentation of 2 MMR’s or a combination of childhood immunizations and 1 MMR. Varicella** #1:Click here to enter text. #2:Click here to enter text.

NA Hepatitis B**

Series 1: #1Click here to enter text. #2Click here to enter text. #3Click here to enter text. Click here to enter text. Choose an item. Date of Declination: (not available to USCSM- Greenville or Columbia students)

Series 2: #1Click here to enter text. #2Click here to enter text. #3Click here to enter text. Click here to enter text. Choose an item. Date:Click here to enter text. Influenza (annual requirement) Click here to enter a date. NA NA Approved Exemption:

Date:Click here to enter text. Health Information: Health problems/physical limitations – indicate any: ☐ N/A Click here to enter text. Allergies: list all e.g. Drug, vaccine, latex, food: ☐ N/A Click here to enter text. Contraindications for requirements: list all and explain: ☐ N/A Click here to enter text. SIGNATURE: ☐I have provided the information requested on this form to the best of my knowledge. Click here to enter text. Click here to enter a date.