Office of Documentation Surveillance

March 1, 2019

Dear First Year Medical Students,

Welcome to Drexel University College of Medicine!

Below is a description of the health‐related requirements that must be completed prior to

matriculation. All forms, including the required lab studies, must be completed and returned to the
Office of Documentation Surveillance no later than July 1, 2019. Incomplete or unreadable forms
cannot be accepted.
Pre‐Matriculation Medical Evaluation Forms
Pre‐Matriculation Medical Evaluation Forms contain a Basic Health Questionnaire for you to complete
as well as a Physical Examination form that must be completed by your health care provider (Page 1).
In addition, your health care provider must submit documentation of the required disease surveillance
and immunizations utilizing the forms below (Disease Surveillance and Immunization Records Pages 2,
3, and 4).

Disease Surveillance and Immunization Requirements

For the complete description of health policy requirements and documentation as well as required
disease surveillance and immunization requirements for medical students, please refer to the Drexel
University College of Medicine Student Handbook, Section 4:
(https://webcampus.drexelmed.edu/handbook/pdf/DrexelMed-MedStudentHandbook.pdf)

Screening for Tuberculosis**

A Two‐Step Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) blood test is
required for all incoming medical students, regardless of prior BCG vaccine status. The second
step of the TST or the IGRA must be completed within three months of matriculation to medical school
(i.e. after May 1, 2019).

If you have a history of a positive TST or a positive IGRA blood test, you must provide
documentation of 9 months of isoniazid (INH) or 4 months of Rifampin preventative treatment and a
negative Chest X‐ray (taken within one year of matriculation to Drexel University College of
Medicine).

In addition to the matriculation requirements, the College of Medicine also requires annual
tuberculosis surveillance testing with a single TST or IGRA for actively enrolled students. If annual
testing reveals a newly positive result, students must get a Chest X-ray and be evaluated by their
health care provider. Documentation of Chest X-ray results, and either treatment for active disease
or preventative therapy with INH or Rifampin, must be provided.

Hepatitis B**
All medical students are required to be vaccinated with the complete 3-dose Hepatitis B vaccine
series. Documentation of administration of the complete vaccine series must be submitted prior to
matriculation. In addition, students must complete and submit post-vaccination quantitative
serologic testing, documenting protective Hepatitis Surface Antibody (anti-HBs) titers. If a student’s
post-vaccination quantitative anti-HBs titer is inadequate, the student must receive one additional dose of
2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
Office of Documentation Surveillance

Hepatitis B vaccine, followed by quantitative anti-HBs serologic testing 1-2 months following receipt of the
additional dose. Students whose titer remains inadequate following the single additional vaccine dose must receive
two (2) additional vaccine doses (6 doses total) followed by repeat quantitative anti-HBs serologic testing 1-2
months after the last dose. If the anti-HBs titer remains negative after completion of two 3-dose vaccine series, a
Hepatitis B Surface Antigen (HBsAg) titer is needed. If HBsAg is positive, student must be evaluated by a
physician; documentation must be provided only stating that the student has been seen and evaluated (no other
details are needed).

Measles/Mumps/Rubella
All students are required to provide written documentation of vaccination with two doses of the
Measles/Mumps/Rubella (MMR) vaccine; documentation must include specific dates of vaccine
administration. Students without documentation of two MMR vaccine doses, must submit
documentation of serologic testing indicating adequate protective antibody titers for Measles,
Mumps and Rubella. Students without required documentation of vaccination or inadequate or negative
antibody titers must receive appropriate vaccinations (and submit documentation) prior to
matriculation.

Tetanus, Diphtheria, Pertussis

Students must provide documentation of a single dose of the adult Tdap vaccination (regardless of
timing of last Td booster). Td boosters are required every 10 years thereafter.

Varicella
Students must provide documentation of immunity to varicella by 1) submitting documentation of
receipt of two doses of the varicella vaccine (documentation must include dates that each vaccine
dose was administered) or 2) submitting documentation of quantitative serologic testing indicating
adequate antibody titers in blood. If a student has a history of varicella disease but serology demonstrates
inadequate or negative antibody titers, the student must receive two doses of vaccine and provide
documentation of vaccination prior to matriculation.
Physical Examination
You must have a physical examination within 12 months of matriculation to medical school.
Your health care provider must utilize the Pre‐Matriculation Medical Evaluation Form to document
his/her findings. If you have any questions, please contact the Office of Documentation Surveillance
at (215) 991‐8560 or immsurv@drexel.edu.

REMINDER: All documentation is due no later than July 1, 2019. All students matriculating to
Drexel University College of Medicine must submit all health‐related requirements/forms by close of
business on Monday, July 1st. Additional required documentation is only to be attached as requested.
DOCUMENTATION OF MEDICAL RECORDS WITHOUT THE COMPLETED DREXEL
FORM WILL NOT BE ACCEPTED. Students who do not submit all required documents
will not be able to begin classes.

Sincerely,

Kelsey Crowley
immsurv@drexel.edu
** A letter has been provided on the next page for your provider to help ensure the corrects tests are ordered to comply with
requirements.

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
Office of Documentation Surveillance

Dear Physician-

Your patient has been offered acceptance to Drexel University College of Medicine. As part of the
admission they must have very specific documentation of Immunization and Disease Surveillance. The
student has a complete list of necessary documentation for matriculation. I would like to highlight the
following areas which have caused confusion in the past.

Hepatitis B
There must be documentation of a complete 3-dose Hepatitis B vaccine series.

There must be documentation of a Quantitative Hepatitis B Surface Antibody Titer. While we

recognize that this is not regularly performed for the general population, the student must have this
exact test documented to participate in any clinical activity.

If the quantitative Hepatitis B surface Antibody Titer is inadequate the student must receive
one additional dose of the vaccine followed by a repeat Quantitative Hepatitis B Surface Antibody
Titer 1-2 months after vaccination. IF the student’s titer remains inadequate they must complete the
entire Hepatitis B vaccination series.

Tuberculosis Screening
A Two-Step Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) blood test is
required, regardless of prior BCG vaccine status.

The Two-Step Tuberculin Skin Test consists of a First PPD being placed and interpreted as negative-
followed by a second PPD placement and interpretation at least one week after the initial PPD
placement, but no more than 12 months apart.

The Second Tuberculin Skin Test MUST be initiated after May 1, 2019 to meet the requirement of the
College of Medicine.

If the student has tested positive in the past via TST or IGRA documentation must be provided for 9
months of isoniazid OR 4 months of Rifampin preventative treatment AND a negative Chest X-Ray.
The Chest X-ray must be completed within 1 year of matriculation (after August 15, 2018).

Dana C. Farabaugh, MD
Associate Dean of Clinical Education
Associate Professor, Obstetrics &Gynecology

College of Medicine
Drexel University
2900 Queen Lane, Room 114K
Philadelphia, PA 19129
Tel: 215-991-8360 | Fax: 215-843-7738
dc47@drexel.edu

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
 Office of Documentation Surveillance

Pre‐Matriculation Health Questionnaire (To be completed by Student)Date Form Completed:___/____/____

Student Last Student First Middle
Name: Name: Initial:
DOB: / / Age: Primary Email:
Street Address: City:

Cell: State: Zip Code:

Family History:
Has anyone in your immediate family had any of the following: Please circle yes or no.

Heart Disease Yes No Diabetes Yes No

High Blood Pressure Yes No Cancer Yes No
Stroke Yes No Tuberculosis Yes No
Sudden Death (before 50) Yes No Asthma Yes No
Epilepsy Yes No Gout Yes No
Migraine Headaches Yes No Marfan’s Syndrome Yes No
Eating Disorder Yes No Sickle Cell Yes No

Personal History:
Have you ever been hospitalized? Yes No
Have you ever had surgery? Yes No
Are you presently under a doctor’s care? Yes No

Please give dates and any details for questions answered yes

Please list any medications you are currently taking and for what conditions

Please list any known allergies

Have you ever had a head injury/concussion? Yes No

Have you ever been knocked unconscious? Yes No
Have you ever had a seizure or epilepsy? Yes No
Do have recurring headaches or migraines? Yes No
Please give dates and details for questions answered yes.

I hereby state that, to the best of my knowledge, my answers to the above questions are correct.

Student Signature_______________________________________ Date Signed _/ /

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
 Office of Documentation Surveillance

Physical Examination: Must be completed and signed by licensed healthcare provider.

Last First Middle:
Name: Name:

Height: Weight:_ Blood Pressure Pulse:_ DOB: /_ /

Visual Acuity: OD_ OS OU Corrected Yes / No

Hearing: Intact / Abnormal ‐ explain:

Clinical Evaluation: Normal Abnormal Comments

1. Skin
2. Head, Ears, Eyes, Nose, Throat
3. Mouth, Teeth, Gums
4. Neck and Thyroid
5. Lungs/Chest
6. Breasts
7. Heart (supine and standing)
8. Abdomen
9. Genitalia
10. Back/Spine
11. Extremities/Musculoskeletal/Femoral Pulses
12. Neurologic
13. Emotional/Psychological
14. Other findings

This student is able to meet the physical and emotional demands of medical school:
Yes No
If no, please explain: _________________________________________________________________________

I have examined this student and attest the above information is accurate and complete to the best
of my knowledge.
Health Care Provider Signature:
Date: / /
Printed Name:

Degree: MD DO ____ (other, please specify)

Address:
City, State, Zip:
Phone:

Page 1 of 5

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
 Office of Documentation Surveillance

Disease Immunization and Surveillance Records: Must be completed and signed by licensed
healthcare provider.

Student Last Student First Middle

Name: Name: Initial:
DOB: Street Address:

Cell Phone: City:

Primary State:
Email:
Alternate Zip Code:
name:

**DOCUMENTATION OF MEDICAL RECORDS WITHOUT THE COMPLETED DREXEL IMMUNIZATION FORMS WILL NOT BE ACCEPTED.**

Tetanus‐diphtheria‐pertussis – One dose of adult Tdap. If last Tdap is more than ten years old, Td booster
should be given.
Date
Tdap Vaccine / /
Tetanus‐diphtheria‐
pertussis
Td Vaccine (if more than 10 years since Tdap) / /

MMR (Measles, Mumps, Rubella) – Two doses of the MMR vaccine or serologic proof of immunity for
Measles, Mumps and Rubella. Copy of lab report must be attached.

Option 1 Vaccine Date

MMR Dose #1 / /
MMR
2 doses of MMR vaccine
MMR Dose #2 / /

Option 2 Serologic Tests Dates

Measles Serologic Immunity (IgG, antibodies, titer) / /  Copy Attached
Mumps Serologic Immunity (IgG, antibodies, titer) / /  Copy Attached
Rubella Serologic Immunity (IgG, antibodies, titer) / /  Copy Attached

Page 2 of 5

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
 Office of Documentation Surveillance

Student Last Student First Middle

Name: Name: Initial:

Hepatitis B – Three doses of vaccine followed by a QUANTITATIVE Hepatitis B Surface Antibody (anti-HBs)
titer. If Quantitative anti-HBs titer is inadequate, must receive one additional dose of Hepatitis B vaccine, followed
by Quantitative anti-HBs serologic testing 1-2 months following receipt of the additional dose. If Quantitative anti-HBs
titer remains inadequate, must receive two (2) additional vaccine doses (6 doses total) followed by repeat Quantitative
anti-HBs serologic testing 1-2 months after the last dose. If anti-HBs titer remains negative after the second series
(6 vaccine doses), a Hepatitis B Surface Antigen titer is needed.
Date
Hepatitis B vaccine dose #1 / /
Primary
Hepatitis B
Hepatitis B vaccine dose #2 / /
Series*
Hepatitis B vaccine dose #3 / /

Quantitative Hep B Surface Antibody  Copy Attached

/ /

Hepatitis B Vaccine Hepatitis B vaccine dose #4

/ /
Non-Responder* (if
Hepatitis B Surface Ab
negative after primary Quantitative Hep B Surface Antibody  Copy Attached
series) (1-2 mos after single additional dose (#4) ) / /

Hepatitis B vaccine dose #5 / /

Hepatitis B Vaccine
Non-Responder after
Additional Vaccine Hepatitis B vaccine dose #6 / /
Dose #4* (if titer
inadequate after single Quantitative Hep B Surface Antibody
(1-2 mos after final (6th) vaccine dose)
/ /  Copy Attached
booster dose (#4)

Hepatitis B Vaccine
Non‐Responder (if
Hepatitis B Surface Antigen / /  Copy Attached
antibody titers
Date of physician
inadequate after 6
If Hepatitis B Surface Antigen positive, evaluation:
doses of vaccine)
physician evaluation required. / /

*See attached letter from Dr. Dana Farabaugh regarding specific requirements.
Page 3 of 5

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
 Office of Documentation Surveillance

Student Last Student First Middle

Name: Name: Initial:

Tuberculosis Screening – A Two‐Step Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) blood test is
required for all incoming medical students. This is required regardless of prior BCG status.
If you have a history of a positive PPD or a positive IGRA blood test, you must provide documentation of 9 months of
isoniazid (INH) or 4 months of Rifampin preventative treatment and a negative Chest X‐ray (taken within one year of
i l i ) Tuberculosis Screening History
Section A Date Placed Date Read Reading Interpretation
Positive
TST #1 / / Negative
Please complete one TB section only*

____mm
Negative / / Within 12 months of
Equivocal
Tuberculin matriculation
Skin Tests or Positive
IGRA Blood TST #2 / / Negative
Test* / / Within 3 months of ____mm Equivocal
matriculation
(Section A or B or C)

Two Tuberculin skin Date Result

tests or
IGRA blood test
required IGRA Blood Test / / Negative
(Interferon gamma releasing assay) Within 3 months of
Indeterminate  Copy Attached
matriculation
Section B Date Placed Date Read Reading

Positive TST / / / / ____mm

History of
Latent Date Result
Tuberculosis:
( Positive Positive IGRA Blood Test / / ___ IU
 Copy Attached
Tuberculin Skin
Test or Positive Chest X‐Ray / /
 Copy Attached
IGRA Blood
Test)* Isoniazid (INH) Rifampin
Preventative Treatment for
Latent TB Start Date End Date
Chest x‐ray must be
within 12 months of / / / /
Section C

Date of Diagnosis / /
History of Active
Tuberculosis*
Medications:

Treatment for Active TB Start Date End Date

/ / / /

Date of Last Chest X-ray / /  Copy Attached

*See attached letter from Dr. Dana Farabaugh regarding specific requirements. Page 4 of 5

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexel.edu
 Office of Documentation Surveillance

Student Last Student First Middle

Name: Name: Initial:

Varicella – Two doses of the Varicella vaccine or serologic proof of immunity for Varicella. Copy of lab report
must be attached.
Date
/ /
Varicella Dose #1
Option 1
/ /
Varicella Dose #2

Option 2 Serologic Immunity

/ /  Copy Attached

**DOCUMENTATION OF MEDICAL RECORDS WITHOUT THE COMPLETED DREXEL IMMUNIZATION

FORMS WILL NOT BE ACCEPTED.**

I attest that the above disease immunization and surveillance records are accurate.

Health Care Provider Signature: Date : / /

Printed Name:

Degree: MD DO ____ (other, please specify)

Address:
City, State, Zip:
Phone:

Revised 20190107

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 Office of Documentation Surveillance

Office of Student Immunization & Surveillance

Drexel University College of Medicine

Any questions should be directed to Kelsey Crowley, immsurv@drexelmed.edu, 215‐991‐8560.

Health and immunization and other documentation records are maintained for current
medical students as part of the academic record necessary for rotation placement. Documents
are destroyed following graduation or when a student is no longer enrolled. We recommend
that you maintain a copy of your health/immunization record with both your personal
physician and with your own personal records.

We strongly recommend that you retain a copy of all documents for your personal records prior to
forwarding a copy to the medical school. Records should be forwarded to the address below.

Office of Documentation Surveillance

Drexel University College of Medicine
2900 Queen Lane – Room 201
Philadelphia, PA 19129

You can also submit completed documents via fax or email.

Signed, readable PDF documents can be sent to immsurv@drexelmed.edu

Signed, readable documents may be faxed to: 215‐843‐7738.

All documents must clearly identify the student’s full name and AMCAS ID #.

All documents are due no later than Monday, July 1, 2019.

**DOCUMENTATION OF MEDICAL RECORDS WITHOUT THE COMPLETED

DREXEL IMMUNIZATION FORMS WILL NOT BE ACCEPTED.**
(Do Not Return This Page)

Revised 20190107

2900 W. Queen Lane, Room 201, Philadelphia, PA 19129 | Tel: 215.991.8560 | Fax: 215.843.7738 drexelmed.edu | immsurv@drexelmed.edu