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CUYAHOGA COMMUNITY COLLEGE HEALTLH CAREERS PROGRAMSIMMUNIZATION FORMProgram NameStudent NameTri-C S# DOBAll Health Career and Nursing students are required to attend internship/clinical/practicum experiences at external and/or internal facilities. Thesefacilities have outlined specific immunization obligations mandated for entrance. These immunization obligations may vary from facility to facility;however all immunization obligations are accounted for in the listing of required immunizations above. The inability of a student to obtain one ormore of the required immunization for personal, religious and/or medical reasoning, may bar that student from beginning or completing theirinternship/clinical/practicum experience at one more facilities. The inability of the program to place a student in a facility forinternship/clinical/practicum experience, based upon a student’s inability to obtain one or more required immunizations, may cause a student to bedenied entrance into the program or dismissed from the program. Students who are not able to obtain all required immunizations should contact theirprogram manager as soon as possible.If using this form for proof of immunity, each signature box must be signed next to any immunization information entered.RequirementTdap Documented single dose of Tdap, (must be Tdap –Dtap, DT, DTP not acceptable) or Positiveantibody titer for all three diseasesTd is required every 10 years after the TdapDate of immunizationorDate and Result of Titer DrawnHealthcare Provider SignatureTiter: TetanusDate:Results: Positive / Negative/ Equivocal(circle one)Titer: DiphtheriaDate:Results: Positive / Negative/ Equivocal(circle one)Sign:Titer: PertussisDate:Results: Positive / Negative/ Equivocal(circle one)ORDate of vaccine:MMR- Measles (Rubeola) Serologic evidence of immunity (positive titer) orif titer is negative, documentation of vaccinationwith two does of measles vaccine- Mumps Serologic evidence of immunity (positive titer) orif titer is negative, documentation of vaccinationwith two does of mumps vaccineTiter: MeaslesDate:Results: Positive / Negative/ Equivocal(circle one)Sign:If negative titerDate of Vaccine:#1#2Titer: MumpsDate:Results: Positive / Negative/ Equivocal(circle one)Sign:If negative titerDate of Vaccine:#1Page 1STUDENT soft\windows\temporary internet files\content.outlook\527bh0du\immunization form in revision 6 22 15.docx
#2- Rubella Serologic evidence of immunity (positive titer) orif titer is negative, documentation of vaccination ofone dose of rubella vaccineHepatitis BWritten documentation of 3 doses of vaccine and/or proof ofpositive titer.Titer: RubellaDate:Results: Positive / Negative/ Equivocal(circle one)If negative titerORDate of Vaccine:#1Date of Vaccine:#1#2#3Sign:Sign:AND/ORTiter:Date:Results: Positive / Negative/ Equivocal(circle one)Tuberculosis Documentation of a negative 2-step TST (DoubleMantoux) within the last 12 monthsorDocumentation of two negative 1-step TST within oneyear period (most recent within last 12 months)orDocumentation of previous 2-step PLUS subsequentannual 1-step testorDocumentation of a negative QuantiFERON Gold or TSpot test within the past 12 months If TB results are positive due to latent tuberculosisdisease, provide a Chest X-Ray (lab report or employerhealth report required). Only one chest X-ray isrequired. If INH therapy was received, you must submitdocumentation of this as well. Students with a positiveresult due to latent TB are required to show proof that nosigns of active TB are present through a medicalprovider verification statement annually.STEP 1Date GivenDate ReadResultSTEP 2Date GivenDate ReadResultSign:ORIGRA blood test i.e.: QuantiFERON-TBDate:Result:ORLast Two Annuals (or enter one annualdate and result in addition to two-step ifno two-step in the last 12 months)Date:Result:Date:Result:-Tuberculosis (Single PPD) A single PPD is requiredannuallyVaricella -Chicken Pox, Herpes Zoster(Shingles) Serologic evidence of immunity (positive titer) or if titer isnegative, documentation of two doses of varicella vaccine 4-8weeks apart is requiredTiter:Date:Results: Positive / Negative/ Equivocal(circle one)Sign:If negative titerPage 2STUDENT soft\windows\temporary internet files\content.outlook\527bh0du\immunization form in revision 6 22 15.docx
Date of Vaccine:#1#2Influenza VaccineDocumentation of annual influenza vaccination. (BetweenAugust 1 and October 1). Timing is subject to change basedon vaccine supply and clinical affiliate request. Please consultwith your program manager.Date of Vaccine:Vet Tech ONLYDate of Vaccine:#1#2#3Vision ExamDate of Exam:Pre-Exposure Rabies VaccineSign:Sign:Sign:Documentation and results of exam must be provided.(Optical Programs, MLT, Phlebotomy and DentalHygiene ONLY)Color Blindness TestDate of Exam:Sign:(MLT and Phlebotomy ONLY)Dental Exam with Radiographic ImagesDate of Exam:Sign:Documentation and results of exam must be provided.(Dental Hygiene ONLY)Provider Information:Facility Name (If applicable):Provider Name:Provider Credentials:Provider Address:Provider Phone:(If more than one provider is used to verify immunizations – provider information for all providers signing off on immunizationsrequirements must be listed)Page 3STUDENT soft\windows\temporary internet files\content.outlook\527bh0du\immunization form in revision 6 22 15.docx
HEALTH RELEASE FORMThis is to certify that had a physicalexam on and is in apparent good health, has no condition that would endanger thehealth and well-being of other students or patients, and is physically/mentally able to participate in theHealth Career/Nursing Program at Cuyahoga Community College.Provider’s Signature:Printed Name:Address:Office Phone Number:Comments:I certify by my signature that this information is true and that I can provide documentation, upon request.Student’s Signature:Printed Name: Date:Page 4STUDENT soft\windows\temporary internet files\content.outlook\527bh0du\immunization form in revision 6 22 15.docx
HEALTH INSURANCE ATTESTATIONStudent Name:Name of Insured:Relationship to Insured:Insurance Provider:Policy Number:Group Number:I certify by my signature that this information is true. I , attestthat as required by law, I have a current health insurance plan which I will maintain through the entirety ofthe health career program. I understand that I am required to present proof of my health insurance plan to aclinical agency or Cuyahoga Community College immediately upon request.Student’s Signature:Printed Name: Date:Page 5STUDENT soft\windows\temporary internet files\content.outlook\527bh0du\immunization form in revision 6 22 15.docx
Tri-C S#_ DOB _ All Health Career and Nursing students are required to attend internship/clinical/practicum experiences at external and/or internal facilities. These facilities have outlined specific immunization obligations mandated for entrance. . Health Career/Nursing Program at Cuyahoga Community College. Provider's Signature .
