Covid Vaccine

TB PPD 1 step
TB PPD 2 step
Hep B vaccination 1,2,3
Hep B titers
MMR + Varicella Vaccinations + Tdap
MMR titers
Influenza Vaccine
Hep C titers
BLS
ACLS
Health Insurance
Drug Screen
 AAMC Standardized Immunization Form

Middle
Last Name: Amerie First Name: Lana Initial:
DOB: Street Address: 2106 26th street
Medical School: Idaho College of Osteopathic Med City: Great Falls
Cell Phone: (530)-760-9381 State: Montana
Primary Email: lamerie@s.idahocom.org ZIP Code: 59405
AAMC ID:

MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1)
dose of Rubella; or serologic proof of immunity for Measles, Mumps and/or Rubella. Choose only one option. Copy
Text of measles or mumps if original MMR vaccination
Note: a 3rd dose of MMR vaccine may be advised during regional outbreaks
was received in childhood. Attached
Option1 Vaccine Date

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

Option 2 Vaccine or Test Date

Measles Vaccine Dose #1 02/15/08 Serology Results

Measles
-2 doses of vaccine or Measles Vaccine Dose #2 11/29/11 Qualitative
Titer Results: Positive Negative
positive serology
Serologic Immunity (IgG antibody titer) 07/13/18 Quantitative
Titer Results: 39.3
_____ IU/ml

Mumps Vaccine Dose #1 02/15/08 Serology Results

Mumps
-2 doses of vaccine or Mumps Vaccine Dose #2 11/29/11 Qualitative
Titer Results: Positive Negative
positive serology
Serologic Immunity (IgG antibody titer) 07/13/18 Quantitative
Titer Results: 12.6
_____ IU/ml
Serology Results
Rubella
-1 dose of vaccine or Rubella Vaccine 11/29/11 Qualitative
Titer Results: Positive Negative

positive serology
Serologic Immunity (IgG antibody titer) 07/13/18 Quantitative
Titer Results: 1.71
_____ IU/ml

Tetanus-diphtheria-pertussis – 1 dose of adult Tdap; if last Tdap is more than 10 years old, provide date of last Td or Tdap booster

Tdap Vaccine (Adacel, Boostrix, etc) 07/06/15

Td Vaccine or Tdap Vaccine booster (if
more than 10 years since last Tdap)

Varicella (Chicken Pox) - 2 doses of varicella vaccine or positive serology

Varicella Vaccine #1 02/15/08 Serology Results

Varicella Vaccine #2 11/29/11 Qualitative

Titer Results: Positive Negative

Serologic Immunity (IgG antibody titer) Quantitative

Titer Results: _____ IU/ml
Influenza Vaccine --1 dose annually each fall

Date

Flu Vaccine 09/17/20

2020 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution. Page 1 of 4
 AAMC Standardized Immunization Form
Amerie, Lana
Name: _____________________________________________________ 12/13/1989
Date of Birth: _________________
(Last, First, Middle Initial) (mm/dd/yyyy)

Hepatitis B Vaccination --3 doses of Engerix-B, Recombivax or Twinrix or 2 doses of Heplisav-B followed by a QUANTITATIVE Hepatitis Copy
B Surface Antibody (titer) preferably drawn 4-8 weeks after the last dose. If negative titer (<10 IU/ml) complete a second Hepatitis B series
followed by a repeat titer. If Hepatitis B Surface Antibody titer is negative after a secondary series, additional testing including Hepatitis B Surface
Attached
Antigen should be 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 (Engerix-B, Recombivax,

Twinrix) or 2-dose vaccine (Heplisav-B)
3 Dose Series 2 Dose Series

Primary
Hepatitis B Series
Hepatitis B Vaccine Dose #1 05/25/18
Heplisav-B only requires Hepatitis B Vaccine Dose #2 06/25/18
two doses of vaccine
followed by antibody
testing
Hepatitis B Vaccine Dose #3 01/10/19
QUANTITATIVE Hep B Surface
Antibody 07/17/19 >11.5
_______ IU/ml

3 Dose Series 2 Dose Series

Secondary
Hepatitis B Series
Hepatitis B Vaccine Dose #4
Only If no response
to primary series Hepatitis B Vaccine Dose #5
Heplisav-B only requires
two doses of vaccine Hepatitis B Vaccine Dose #6
followed by antibody
testing QUANTITATIVE Hep B Surface
Antibody _______ IU/ml

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 Vaccines

Some states and institutions may have additional vaccine requirements for students, health sciences personnel, and first
responders depending upon assignment, school requirements or state law. Examples include meningitis vaccine which is
mandated in some states for incoming students.

Date
Vaccination

Meningococcal Vaccine ACWY

Additional Comments

© 2020 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution. Page 2 of 4
 AAMC Standardized Immunization Form
Amerie, Lana
Name: _____________________________________________________ 12/13/1989
Date of Birth: _________________
(Last, First, Middle Initial) (mm/dd/yyyy)
CDC Recommendations: Preplacement (baseline) TUBERCULOSIS SCREENING AND TESTING of all health care
personnel/ trainees consists of a TB symptom evaluation, a TB test (IGRA or TST), and an individual TB risk assessment.
You only need to complete ONE section below: A or B or C.
Section A: If you do not have a history of TB disease or LTBI (Latent Tuberculosis Infection), the results of a 2-step TST
(Tuberculosis Skin Test), or TB IGRA (Interferon Gamma Release Assay) blood test are required, regardless of your prior BCG
status. You should also check off the results of your individual baseline TB symptom evaluation and TB risk assessment
questionnaire.
Section B: If you have a history of a positive TST (PPD)>10mm or a positive IGRA, please supply information regarding further
medical evaluation and treatment below.
Section C: History of active tuberculosis, diagnosis and treatment.

Health Care Personnel with a baseline NEGATIVE Skin Test result or a NEGATIVE IGRA blood test and
negative symptom evaluation will receive annual TB education; additional TB screening may be recommended by state or
local health departments for certain occupational high risk groups.

Tuberculosis Screening History

Copy
Section A Date Placed Date Read Result Interpretation Attached

TST step #1 05/18/18 05/21/2018 0

____mm Pos Neg Equiv
Please complete only one TB section based on your history

No history of TST step #2 06/06/18 06/08/18 0

____mm Pos Neg Equiv
prior TB Disease T
or LTBI e Date Result
Dates of the last
2-step TST or TB IGRA QuantiFERON TB Gold or T-Spot Negative Indeterminate
blood test are required (Interferon Gamma Release Assay)

(IGRAs include QuantiFERON TB Gold or T-Spot

QuantiFERON TB Gold
(Interferon Gamma Release Assay)
Negative Indeterminate
Test, QuantiFERON TB
Gold in-tube test, or T-spot
TB Test)
Individual TB Symptom Negative Positive
Assessment (Medical follow-up needed)
Negative Positive
Individual TB Risk Assessment
(Increased risk TB infection)
Section B Date Placed Date Read Result

Positive TST _______ mm

History of Date Result

LTBI, QuantiFERON TB Gold or T-Spot Positive Negative Indeterminate
Positive TB Skin (Interferon Gamma Release Assay)
Test, or
Positive TB IGRA Chest X-ray _________________________________
Blood Test
Treated for latent TB? Yes No
(IGRAs include
QuantiFERON TB Gold
Test, QuantiFERON TB
Gold in-tube test, or T-spot If treated for latent TB, list medications taken:
TB Test)

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

© 2020 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution. Page 3 of 4
 AAMC Standardized Immunization Form
Amerie, Lana
Name: _____________________________________________________ Date of Birth: _________________
12/13/1989
(Last, First, Middle Initial) (mm/dd/yyyy)

MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER OR INSTITUTIONAL DESIGNEE:

Authorized Signature: Date: 04/19/2021

Printed Name: Caitlyn Frakes

Office Use Only
Title: Clinical Clerkship Coordinator
Address Line 1: 1401 E. Central Drive
Address Line 2:

City: Meridian
State: Idaho
Zip: 83642
Phone: 208 795
(____) 4343
______-____________ Ext: _______

Fax: (____) 510 0157

208 ______-____________

Email Contact: cfrakes@idahocom.org

*Sources:
1. Kim DK, Hunter P. Advisory Committee on Immunization Practices: Recommended Immunization Schedule for Adults Aged 19 years or Older—United States,
2019. MMWR 2019; 68:115-118. http://dx.doi.org/10.15585/mmwr.mm6805a5.
2. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 2011, Vol 60(RR077):1-45
3. Schillie S, Harris A, Link-Gelles R. et al. Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel
Adjuvant. MMWR 2018;67;455-8. https://doi.org/10.15585/mmwr.mm6715a5.
4. Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National
Tuberculosis Controllers Association and CDC, 2019. MMWR 2019;68:439-443. https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm.
5. Centers for Disease Control and Prevention. Tuberculosis (TB) Screening, Testing, and Treatment of U.S. Health Care Personnel Frequently Asked Questions
(FAQs). https://www.cdc.gov/tb/topic/infectioncontrol/healthcarepersonnel-faq.htm.

© 2020 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution. Page 4 of 4
Hep B 1st and 2nd Vaccination
Hep B 3rd Vaccination
Hep 1st and 2nd Dose
Tdap
Hep C titers
 B A S I C L I F E S U P P O R T

BLS
Provider

Lana Amerie
has successfully completed the cognitive and skills
evaluations in accordance with the curriculum of the
American Heart Association Basic Life Support
(CPR and AED) Program.

Issue Date Recommended Renewal Date

7/2/2020 07/2022

Training Center Name Instructor Name

Ada County Emergency Medical Services District
Lisa Damron

Instructor ID
Training Center ID
02180651938
ID20735
eCard Code
Training Center Address
205503938029
370 N. Benjamin Lane
Boise ID 83705 USA QR Code

Training Center Phone

Number
(208) 287-2973

To view or verify authenticity, students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards.
© 2016 American Heart Association. All rights reserved. 15-3001 3/16
A DVA N C E D CA R D I OVA S C U L A R LI F E S U P P O R T

ACLS
Provider

has successfully completed the cognitive and skills evaluations

in accordance with the curriculum of the American Heart Association
Advanced Cardiovascular Life Support (ACLS) Program.

Issue Date Renew By

Training Center Name Instructor Name

Instructor ID
Training Center ID

eCard Code
Training Center City, State

QR Code
Training Center Phone
Number

To view or verify authenticity, students and employers should scan this QR code with their mobile device or go to www.heart.org/cpr/mycards.
© 2020 American Heart Association. All rights reserved. 15-3000 R3/20
SCREENING REPORT

Results for

Lana Amerie
xxx-xx-3406

SERVICE STATUS
Drug Screening Clear
Test Type: NON DOT - Pre-Employment
Test Panel: 10 panel with MDMA
Specimen ID: QD18068714
Date Collected: 06/18/2021
Collection Site: Quest - Great Falls
401 S. 15th Ave.
Great Falls, Montana 59405
406-750-7795
Laboratory: Quest Diagnostics
Lab Remarks: None
MRO Final Verification: Negative
Comments: None

Idaho College of Osteopathic Medicine –

Client / Code: Report #: 13581557
School Pay / 003
Results Delivered to:
Sara Reiter / NONE Delivery Date: 07/01/2021

Personal & Confidential

This report is to only be used in strict adherence to the terms and conditions set forth in the Agreement
between Certiphi Screening and its client. © Certiphi Screening, Inc., 2021. All rights reserved. Certiphi
Screening, Inc. is a subsidiary company of Vertical Screen, Inc. Direct any questions to Certiphi Screening,
P.O. Box 541, Southampton, PA 18966 USA. Phone: (800) 803-7860; Fax: (888) 260-1380.

End of Report

Lana Amerie Page 1

SCREENING REPORT

Copy of COC - MRO Copy Attached

Lana Amerie Page 3

SCREENING REPORT

Lana Amerie Page 4