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Fisk University - Health Examination Form
(PHYSICIAN IS TO COMPLETE PAGE ONE OF THIS DOCUMENT)
Student's Name_________________________________________________________________ SS #_______- _____- _________
Last First Middle
Part I
MMR Check appropriate box: (RUBELLA)
1. Received two (2) measles since the age of twelve months (Mo./Yr.)_______/________
(Mo./Yr.)_______/________
2. Medically contraindicated because of pregnancy, allergy to vaccine, etc. Must list reason(s)
_________________________________________________________________________________
Part II
Varicella (If you were born after 1980) - Check appropriate box:
1. Dose #1 given at age 12 months or later (Mo./Yr.)_______/________
2. Dose #2 given at age 12 months or later (Mo./Yr.)_______/________
Part II
TETANUS-DIPHTHERIA Check appropriate box:
1. Completed primary series of tetanus-diphtheria immunizations (Mo./Yr.)_______/________
2. Received tetanus-diphtheria booster within the last ten years (Mo./Yr.)_______/________
Part III
MENINGOCOCCAL (A, C, Y, W) Check appropriate box:
1. One dose preferably at entry into college for freshman living in (Mo./Yr.)_______/________
residence halls, and undergraduate less than 25 years wishing to
reduce their risk of disease should consider the vaccine.
Part IV
Please provide year when patient had the following immunizations:
Typhoid (Mo./Yr.)_______/________ Whooping Cough (Mo./Yr.)_______/________
Tetanus (Mo./Yr.)_______/________ Polio (Mo./Yr.)_______/________
Measles (Mo./Yr.)_______/________ Mumps (Mo./Yr.)_______/________
Signature of Physician: ____________________________________Date: ________
Name of Physician: ____________________________________________________
(Please Print)
PLEASE RETURN THIS FORM TO:
By mail:
Fisk University
Office of Residence Life and Campus Services
1000 17
th
Avenue North
Nashville, Tennessee 37208
Or by email:
residencelife@fisk.edu
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(STUDENT IS TO COMPLETE PAGE TWO OF THIS DOCUMENT)
Student's Name_________________________________________________________________ SS #_______- _____- _________
Last First Middle
The General Assembly of the State of Tennessee mandates that each public of private postsecondary institution in the state
provide information concerning hepatitis B infection to all students entering the institution for the first time. Those students
who will be living in on campus housing must also be informed about the risk of meningococcal meningitis infection. The
required information below includes the risk factors and dangers of each disease as well as information on the availability and
effectiveness of the respective vaccines for persons who are at-risk for the diseases. The information concerning these
diseases is from the Centers for Disease Control and the American College Health Association. The law does not require that
students receive vaccination for enrollment. Furthermore, the institution is not required by law to provide vaccination and/or
reimbursement for the vaccine.
A. Hepatitis B (HBV) Immunization
(TO BE COMPLETED BY ALL NEW STUDENTS)
Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and
even death. The disease is transmitted by blood and or body fluids and many people will have no symptoms when they develop the
disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable.
Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are
required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The
HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.
___ I hereby certify that I have read this information and I have received the initial dose of Hepatitis B vaccine.
Date of initial does of the Hepatitis B vaccine: ___/___/___
___ I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine.
Signature of Student or Parent/Guardian (If student is under 18): ______________________________________________ Date:
______________
B. Meningococcal Meningitis -Serotype B (eg. Trumenba or Bexsero)
(TO BE COMPLETED BY ALL NEW STUDENTS)
Meningococcal disease is a rare but potentially fatal bacterial infection, expressed as either meningitis (infection of the membranes
surrounding the brain and spinal cord) or meningococcemia (bacteria in the blood). Meningococcal disease strikes about 3,000
Americans each year and is responsible for about 300 deaths annually. The disease is spread by airborne transmission, primarily
by coughing. The disease can onset very quickly and without warning. Rapid intervention and treatment is required to avoid
serious illness and/or death. There are 5 different subtypes (called sereogroups) of the bacterium that causes Meningococcal
Meningitis. The current vaccine does not stimulate protective antibodies to Serogroups B, but it does protect against the most
common strains of the disease, including serogroups A, C, Y and W-135. The duration of protection is approximately three to five
years. The vaccine is very safe and adverse reactions are mild and infrequent, consisting primarily of redness and pain at the site of
injection lasting up to two days.
The Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC)
recommends that college freshmen (particularly those who live in dormitories or residence halls) be informed about meningococcal
disease and the benefits of vaccination and those students who wish to reduce their risk for meningococcal disease be immunized.
Other undergraduate students who wish to reduce their risk for meningococcal disease may also choose to be vaccinated.
___ I hereby certify that I have read this information and I have received the vaccine for Meningococcal Meningitis.
Date of Meningococcal Meningitis vaccine (Dose 1): ___/___/___ Trumenba or Bexsero
Date of Meningococcal Meningitis vaccine (Dose 2): ___/___/___ Trumenba or Bexsero
Date of Meningococcal Meningitis vaccine (Dose 3): ___/___/___ Trumenba
___ I hereby certify that I have read this information and I have elected not to receive the vaccine for Meningococcal
Meningitis.
Signature of Student or Parent/Guardian (If student is under 18): ______________________________________________ Date:
______________
For more information about Meningococcal Meningitis and Hepatitis B disease and vaccine, please contact your local health care
provider or consult the Center for Disease Control and Prevention Web site at [www.cdc.gov/health/default.htm].
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