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    Immunization-Requirements 2

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    drprashastiprasad
    Immunisation requirements

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    Immunization-Requirements 2

    Uploaded by

    drprashastiprasad
    11 views1 page
    Immunisation requirements

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    immunization-requirements 2

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    Immunisation requirements

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    11 views1 page

    Immunization-Requirements 2

    Uploaded by

    drprashastiprasad
    Immunisation requirements

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    I will be doing a: ☐ clinical rotation/practicum or

    ☐ only shadowing. In what state and town at Mercy? ________________

    Mercy Health System Student/Shadow Vaccination Verification Form


    Legal Name (Print): __________________________________Date of Birth:_______________________
    The required immunizations MUST BE documented on this form. Signature is required by your School Nurse,
    Personal Physician, Nurse Practitioner or Physician Assistant to attest to accuracy.

    TUBERCULOSIS SCREENING (Required)


    Two TB skin tests within the last 12 months. First skin test (required) Second skin test (required 1-3
    These are two TB skin tests with the second weeks after first test)
    TST repeated 7-21 days after first TB skin test Date Placed:
    is read.
    Date Read:
    OR Induration (mm):
    Result (Pos/Neg):
    A TB blood test within the last 12 Date: Result:
    months (IGRA)
    (T-Spot, Quantiferon Gold, etc.)
    Chest x-ray - in the last two years with Date:
    documentation of official report (for positive
    results only)
    REQUIRED IMMUNIZATIONS
    Vaccinations Titer(s)
    Tdap (One vaccine within the last 10 years) Date:
    MMR (#1) AND (#2) Titer AND Titer AND Titer
    Two MMR vaccinations at least 1 month positive positive positive
    apart given after age 1 date: date: date:
    ---OR--- Measles Mumps Rubella
    Born prior to 1957 (exempt)
    ---OR---
    Positive titers to Measles, Mumps, and OR
    Rubella
    ---OR---
    Documentation of 2 Measles, 2 Mumps,
    and 1 Rubella vaccination
    Varicella (chicken pox) - Series of two (#1) AND (#2) OR Titer positive date:
    doses or immunity by positive blood titer
    Flu Vaccine (if at Mercy between October 1 - Date:
    March 31) Date subject to change per CDC
    Hepatitis A (required only for students and N/A OR (#1) AND (#2) OR Hep A Titer Date:
    shadowers in Daycare or Nutrition/Food Service)
    RECOMMENDED IMMUNIZATIONS
    COVID Vaccine date of INITIAL series completion: date of LAST booster: student declined ☐
    Hepatitis B Vaccine Vaccinations Titer
    mo/day/year mo/day/year mo/day/year Titer date/result
    (Hepatitis B vaccine is a 3 vaccine series 1st Series
    that is completed at intervals (#1) (#2) (#3) Date:
    recommended by the CDC. If a negative
    HBsAB is found after a completed first Result:
    series, a second series may be nd
    2 Series (if given)
    indicated. If a second negative HBsAB is (#1) (#2) (#3) Date:
    resulted after a completed second
    series, diagnosis of non-responder.) Result:
    Information MUST be verified and signed by the student/shadower’s School Nurse, personal Physician, Nurse
    Practitioner, or Physician Assistant. Signature attests to accurate immunization documentation.
    ______________________________________________________________/__________________
    Signature (of School Nurse/Physician/Nurse Practitioner/Physician Assistant) with Credentials Date:

    ________________________________________________________/________________________
    Printed Name (of School Nurse/Physician/Nurse Practitioner/Physician Assistant) Office Phone #:
    School or Provider Office Address/City/State:

    Return this form in order to receive approval to start your learning experience at Mercy:
    • Clinical rotation students send to MercyStudentExperiences@mercy.net
    • Shadower/Observers send to MercyShadowExperiences@mercy.net

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