MIDWESTERN UNIVERSITY Glendale Campus Office of Student Services 19555 North 59th Avenue Glendale, AZ 85308 623/572-3210 Certificate of Immunity Form To be completed by health care provider Name: _ Program: _ Student ID#: Date of Birth: _ MEASLES (Rubeola) Two immunizations with live virus vaccine 1st: _ 2nd: _ (month-day-year) (month-day-year) Immunity confirmed by blood titer (valid only with copy of lab report) Date of test: _ (month-day-year) RUBELLA (German Measles) -One immunization with live virus vaccine (month-day-year) Immunity confirmed by blood titer (valid only with copy of lab report) Date of test: (month-day-year) MUMPS -One immunization with live virus vaccine (month-day-year) Immunity confirmed by blood titer (valid only with copy of lab report) Date of test: (month-day-year) TETANUS/DIPHTHERIA (DTP, DT, Td) One immunization (Td) - (must have been received within the last 10 years) NO TITER REQUIRED Date of immunization: _ (month-day-year) (See back page) Rev 1/30/07 HEPATITIS B — ANTIBODY Three doses of Hepatitis B vaccine A blood titer is also required 30 days after the 3rd immunization to prove immunity 1st: _ 2nd: _ 3rd: _ (month-day-year) (month-day-year) (month-day-year) -ANDImmunity confirmed by Hep B Surface Antibody titer (valid only with copy of lab report) Date of test: (month-day-year) TWO-STEP TUBERCULOSIS (TB) SKIN TEST -Each student will need to have an initial two-step baseline TB test (A two-step TB test requires two separate injections and two separate readings) Annual one-step skin tests are required by Midwestern University after an initial two-step baseline TB test If you have tested TB positive before, we will need annual verification from a physician that you not have active tuberculosis or a clear chest x-ray Date of TB test #1 : (month-day-year) Results: Date of TB test #2: (month-day-year) Results: VARICELLA (Chicken Pox) -Immunity confirmed by blood titer (valid only with copy of lab report) Date of test: _ (month-day-year) HEALTH CARE PROVIDER CERTIFICATION AND INFORMATION Name (Print): Credentials / Title: Signature: _ Telephone #: ( ) Fax: ( ) _ Physician/Healthcare provider: For questions please contact Midwestern University Student Services at 623/572-3210 Please return all documentation to: MIDWESTERN UNIVERSITY • ATTN: Student Services 19555 North 59th Avenue • Glendale, AZ 85308 • 623/572-3210 I authorize Midwestern University to release this immunization record to external rotation (clerkship) sites, preceptors, and/or to the Arizona Department of Public Health, or its designated representative, for compliance audits and in the event of a health or safety emergency Student’s Signature _ Date _ Rev 1/30/07 ... -Immunity confirmed by blood titer (valid only with copy of lab report) Date of test: _ (month-day-year) HEALTH CARE PROVIDER CERTIFICATION AND INFORMATION Name (Print):... (month-day-year) (month-day-year) (month-day-year) -ANDImmunity confirmed by Hep B Surface Antibody titer (valid only with copy of lab report) Date of test: (month-day-year) TWO-STEP TUBERCULOSIS... you not have active tuberculosis or a clear chest x-ray Date of TB test #1 : (month-day-year) Results: Date of TB test #2: (month-day-year) Results: