Health and Safety Requirements Worksheet
Name: ____________________________________________________ Date:___________________
Use this worksheet ONLY as a guide to ensure that you have documentation of each requirement.
Supporting documents (lab results, immunization records, signed healthcare provider form, etc.) for each
requirement MUST be included. THIS FORM DOES NOT CONSTITUTE PROOF.
MMR (Measles/Rubeola, Mumps and Rubella) To meet requirement:
1. MMR vaccination: Dates: #1__________ #2__________
OR
2. Date & positive IgG titer results:
Measles: ___________ _____________
Mumps: ___________ _____________
Rubella: ___________ _____________
Varicella (Chickenpox) To meet requirement: History of disease is not sufficient.
1. Varicella vaccination dates: #1__________ #2__________
OR
2. Date & positive results of varicella IgG titer: Date: ___________ Result: ______________
Tetanus/Diphtheria/Pertussis (Tdap) To meet requirement you must provide proof of a one-time Tdap
vaccination and Td booster if 10 years or more since Tdap vaccination
Tdap vaccine: Date: ___________
Td booster: Date: ___________
Tuberculosis: Documentation is required for all tests. For individuals who have not received a TB test within
the past year, will need to receive a 2-Step TB test. This consists of two separate TB test; an initial TB skin
test and a second TB skin test 1-3 weeks apart. After completion of the 2-step, an annual update of TB skin
test is sufficient. If you have a positive skin test, provide documentation of a QuantiFERON test or negative
chest X-ray and annual documentation of a TB disease-free status. Most recent skin testing or blood test
must have been completed within the previous six (6) months.
To meet requirement:
1. Negative 2-step TB Skin Test (TBST), including date of administration, date read, result, and name
and signature of healthcare provider.
Initial Test (#1) Date: __________ Date Read: __________ Results: Negative or Positive
Boosted Test (#2) Date: __________ Date Read: __________ Results: Negative or Positive
2. Annual 1-step TBST (accepted only from continuing students who have submitted initial 2-step
TBST)
Date: __________ Date Read: __________ Results: Negative or Positive
OR
3. Negative blood test (Either QuantiFERON or TSpot)
QuantiFERON Date: __________
T-Spot Date:_________
OR
4. Negative chest X-ray
OR
5. Documentation of a negative chest X-ray (x-ray report) or negative QuantiFERON result and
completed Tuberculosis Screening Questionnaire
Date: __________
