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.