Scribd
Upload
36 views1 page

2025 Immunizations Form

The document is an immunization record form required for the SHSU-COM Summer 1 Internship, which must be completed and returned as a PDF. It outlines various immunizations and tests needed, including Tdap, MMR, tuberculosis, and hepatitis B, along with specific documentation requirements. The form must be submitted by March 27, 2025, to the designated medical school coordinator.

Uploaded by

lemary2504
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
36 views1 page

2025 Immunizations Form

The document is an immunization record form required for the SHSU-COM Summer 1 Internship, which must be completed and returned as a PDF. It outlines various immunizations and tests needed, including Tdap, MMR, tuberculosis, and hepatitis B, along with specific documentation requirements. The form must be submitted by March 27, 2025, to the designated medical school coordinator.

Uploaded by

lemary2504
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

2025

SHSU-COM Summer 1 Internship


IMMUNIZATION RECORD

CERTIFICATE OF COMPLIANCE
Name ___________________________________________ Date of Birth__________________ Phone__________________

Address ______________________________________________________ Email ___________________________________

Complete form and return this form. Additional supporting documentation should not be submitted unless requested.
The certificate of compliance must be returned as a PDF. Dates provided must be based on medical records and not
history only.
DATE
A. Tetanus-Diphtheria-Pertussis (Tdap)
1. Received tetanus-diphtheria-pertussis booster within the last 10 years. Td is not _________________
acceptable.
B. M.M.R. (Measles, Mumps, Rubella) (please document each dose)
1. _______Dose 1: Immunized at 12 months or after. _________________
2. _______Dose 2: Immunized 2nd dose. _________________

C. Measles (Rubeola) - If given instead of M.M.R. check appropriate item


1. _______Serologic proof of immunity. Or, _________________
2. _______Immunization (2 doses) _________________

D. Rubella - If given instead of M.M.R. check appropriate item


1. _______Serologic proof of immunity. Or, _________________
2. _______Immunization (2 doses) _________________
3.
E. Mumps- If given instead of M.M.R. check appropriate item
1. ______Serologic proof of immunity. Or, _________________
2. ______Immunization (2 doses) _________________
3. _________________
F. Varicella (Chickenpox)-History of disease is not acceptable.
1. ______Serologic proof of immunity. Or, _________________
2. ______Immunization (2 doses) _________________

G. Tuberculosis
1. ______IGRA blood test on or after Aug. 31, 2023. (TB skin test is not acceptable) ________________
Give date and test result.
2. ______Had BCG vaccine. If yes, TB blood test still has to be done. _________________
3. ______If ever positive, chest x-ray within last 2 years is required. Provide date of the positive _________________
test. Provide date and result of x-ray. _________________

H. Hepatitis B -give dates for all administered shots


1. ______Serologic proof of immunity. Or, _________________
2. ______Immunization _________________
_________________
_________________

Healthcare Provider Signature Phone

Mailing Address Date

PLEASE RETURN THIS FORM (via email) TO: 03/27/2025

Christopher Truong
JAMP Medical School Coordinator
chris.truong@shsu.edu

You might also like