Health Verification Form
IMMUNIZATIONS AND TB SCREENING
REQUIRED OF ALL F-1 VISA INTERNATIONAL STUDENTS
All students who are attending De Anza College for the first time, must provide the International Student Programs (ISP) office
with written documentation of TB (Tuberculosis) test and immunization of MMR (Measles, Mumps, Rubella) 2 doses
required. If a TB test is positive (measuring higher than 9mm), then proof of chest x-ray is also required. Submit these
proofs during Orientation or to the ISP office.
Failing to submit this form with attached proofs will result in a registration HOLD!
Complete the student’s information section.
Have your doctor complete the Immunization & TB test section and attach medical records as proofs.
Last (Family) Name First Name Middle Name
Students’ Date of Birth (mm/dd/yyyy):
De Anza College Student ID# (if known):
Immunizations – Must be completed by Doctor and attach medical record proof to this form
MMR: (Measles, Mumps, Rubella)
Note: The 2 doses of MMR must be separated by a minimum of 30 days
TB (Tuberculosis Test) – Must be completed by Doctor and attach medical record proof to this form
Note: TB skin test must have been administered within the last 90 days of your arrival to the U.S.
Date of TB Skin Test taken:
YOUR TB skin test results in Millimeters (mm):
If your TB skin Test is positive, you MUST show proof of a chest x-ray.
Date of last chest x-ray:
Doctor’s Signature and stamp:
Remember to attach medical record proofs to this form!
NOTE: If you cannot provide records of TB & MMR from your home country, you will need to take TB & MMR at the De Anza
Health Center on campus.
JN:Health Verification August 2017
International Student Programs
Phone:408.864.8826
Fax: 408.864.5638
Email: dainternational@fhda.edu
