AAMC Standardized Immunization Form
Middle
Last Name: First Name:
Initial:
DOB: Street Address:
Medical School: City:
Cell Phone: State:
Primary Email: ZIP Code:
Student ID:
MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose Copy
of Rubella; or serologic proof of immunity for Measles, Mumps and/or Rubella. Choose only one option. Attached
Option1 Vaccine Date
MMR MMR Dose #1 ___/___/____
-2 doses of MMR
vaccine MMR Dose #2 ___/___/____ ☐
Option 2 Vaccine or Test Date
Measles Vaccine Dose #1 ___/___/_____ Serology Results
Measles
-2 doses of vaccine or Measles Vaccine Dose #2 ___/___/_____ Qualitative
Titer Results: Positive Negative
☐
positive serology
Serologic Immunity (IgG, antibodies,
titer)
___/___/_____ Quantitative
Titer Results: _____ IU/ml
Mumps Vaccine Dose #1 ___/___/_____ Serology Results
Mumps
-2 doses of vaccine or Mumps Vaccine Dose #2 ___/___/_____ Qualitative
Titer Results: Positive Negative
☐
positive serology
Serologic Immunity (IgG, antibodies,
titer)
___/___/_____ Quantitative
Titer Results: _____ IU/ml
Serology Results
Rubella
-1 dose of vaccine or Rubella Vaccine ___/___/_____ Qualitative
Titer Results: Positive Negative
positive serology Serologic Immunity (IgG, antibodies, ☐
titer)
___/___/_____ Quantitative
Titer Results: _____ IU/ml
Tetanus-diphtheria-pertussis – One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide date of last Td and Tdap
Tdap Vaccine (Adacel, Boostrix, etc) ___/___/_____
☐
Td Vaccine (if more than 10 years since last ___/___/_____
Tdap)
Varicella (Chicken Pox) -2 doses of vaccine or positive serology
Varicella Vaccine #1 ___/___/____ Serology Results
Varicella Vaccine #2 ___/___/____ Qualitative
Titer Results: Positive Negative ☐
Quantitative
Titer Results: _____ IU/ml
Influenza Vaccine --1 dose annually each fall
Date
Second flu vaccine is
for updating your form Flu Vaccine ___/___/____ ☐
only
Flu Vaccine ___/___/____
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AAMC Standardized Immunization Form
Name: _____________________________________________________ Date of Birth: _________________
(Last, First, Middle Initial) (mm/dd/yyyy)
Hepatitis B Vaccination --3 doses of Engergix-B, Recombivax or Twinrix or 2 doses of Heplisav-B followed by a QUANTITATIVE Copy
Hepatitis B Surface Antibody (titer) preferably drawn 4-8 weeks after 3rd dose. If negative, complete a second Hepatitis B series followed by a
repeat titer. If Hepatitis B Surface Antibody is negative after a secondary series, additional testing including Hepatitis B Surface Antigen should be Attached
performed. See: http://www.cdc.gov/mmwr/pdf/rr/rr6210.pdf for more information. Documentation of Chronic Active Hepatitis B is for rotation
assignments and counseling purposes only.
3-dose vaccines (Energix-B, Recombivax,
Twinrix) 3 Dose Series 2 Dose Series
2-dose vaccines (Heplisav-B)
Primary Hepatitis B Vaccine Dose #1 ___/___/_____ ___/___/_____
Hepatitis B Series
Hepatitis B Vaccine Dose #2 ___/___/_____ ___/___/_____ ☐
Heplisav-B only requires two
doses of vaccine followed by
antibody testing Hepatitis B Vaccine Dose #3 ___/___/_____
QUANTITATIVE Hep B Surface
___/___/_____ _______ IU/ml
Antibody
3 Dose Series 2 Dose Series
Secondary
Hepatitis B Series Hepatitis B Vaccine Dose #4 ___/___/_____ ___/___/_____
Only If no response to
Hepatitis B Vaccine Dose #5 ___/___/_____ ___/___/_____ ☐
primary series
Heplisav-B only requires two Hepatitis B Vaccine Dose #6 ___/___/_____
doses of vaccine followed by
antibody testing
QUANTITATIVE Hep B Surface
___/___/_____ _______ IU/ml
Antibody
Hepatitis B Vaccine Hepatitis B Surface Antigen ___/___/_____ Positive Negative
Non-responder ☐
(If Hepatitis B Surface Antibody Negative
after Primary and Secondary Series) Hepatitis B Core Antibody ___/___/_____ Positive Negative
Hepatitis B Surface Antigen ___/___/_____ Positive Negative
Chronic Active ☐
Hepatitis B
Hepatitis B Viral Load ___/___/_____ _______ copies/ml
Additional Documentation
Some institutions may have additional requirements depending upon rotation, school requirements or state law. Examples
include meningitis vaccine which is mandated in some states if you live in dormitory style housing. If you will be participating in
an international experience you may also be required to provide proof of vaccines such as yellow fever or typhoid. Respiratory
Fit Testing, etc
Vaccination, Test or Examination Date Result or Interpretation
Physical Exam (if required) ___/___/____ ☐
Respiratory Fit Testing ___/___/____ ☐
___/___/____
___/___/____
___/___/____
___/___/____
___/___/____
___/___/____
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AAMC Standardized Immunization Form
Name: _____________________________________________________ Date of Birth: _________________
(Last, First, Middle Initial) (mm/dd/yyyy)
TUBERCULOSIS SCREENING – Results of last (2) TSTs (PPDs) or (1) IGRA blood test are required regardless of prior BCG
status. If you have a history of a positive TST (PPD)>10mm or IGRA please supply information regarding any evaluation and/or
treatment below. You only need to complete ONE section.
Skin test or IGRA results should not expire during proposed elective rotation dates
or
must be updated with the receiving institution prior to rotation.
Tuberculosis Screening History
Section A Date Placed Date Read Result Interpretation
TST #1 ___/___/____ ___/___/____ ____ mm Pos Neg Equiv
TST #2 ___/___/____ ___/___/____ ____mm Pos Neg Equiv
Please complete only one TB section based on your history
Negative Skin or TST #3 ___/___/____ ___/___/____ ____ mm Pos Neg Equiv
Blood Test
History
TST #4 ___/___/____ ___/___/____ ____ mm Pos Neg Equiv
Last two skin test Date Result
or IGRAs required
T-spots or QuantiFERON
QuantiFERON TB Gold or T-Spot ___/___/____ Negative Indeterminate
(Interferon Gamma Releasing Assay)
TB Gold blood tests for
tuberculosis
QuantiFERON TB Gold or T-Spot ___/___/____ Negative Indeterminate
Use additional (Interferon Gamma Releasing Assay)
rows as needed
QuantiFERON TB Gold or T-Spot ___/___/____ Negative Indeterminate
(Interferon Gamma Releasing Assay)
QuantiFERON TB Gold or T-Spot ___/___/____ Negative Indeterminate
(Interferon Gamma Releasing Assay)
Section B Date Placed Date Read Result
Positive TST ___/___/____ ___/___/___ _______ mm
Date Result
History of
Latent QuantiFERON TB Gold or T-Spot ___/___/____ Positive Negative Indeterminate
(Interferon Gamma Releasing Assay)
Tuberculosis,
Positive Skin
Chest X-ray ___/___/____ _________________________________
Test or
Positive Blood
Test Treated for latent TB? Yes No
IGRAs include T-spots or
QuantiFERON TB Gold If treated for latent TB, list medications taken:
blood tests for tuberculosis
Total Duration of treatment latent TB? _____ Months
Date of Last Annual TB Symptom Questionnaire ___/___/_____
Section C Date
Date of Diagnosis ___/___/____
Date of Treatment Completed ___/___/____
History of Active
Tuberculosis Date of Last Annual TB Symptom Questionnaire ___/___/____
Date of Last Chest X-ray ___/___/____
© 2019 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution. Page 3 of 4
AAMC Standardized Immunization Form
Name: _____________________________________________________ Date of Birth: _________________
(Last, First, Middle Initial) (mm/dd/yyyy)
Additional Information
MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER OR INSTITUTIONAL DESIGNEE:
Authorized Signature: Date: ___/___/____
Printed Name:
Office Use Only
Title:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone: (____) ______-____________ Ext: _______
Fax: (____) ______-____________
Email Contact:
*Sources:
1. Hepatitis B In: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine‐Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds.
13th ed. Washington D.C. Public Health Foundation, 2015
2. Immunization of Health‐Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, Vol 60(7):1‐45
3. CDC Guidance for Evaluating Health‐Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, MMWR, Vol 62(RR10):1‐19
4. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, MMWR Vol 67(1):1‐31
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