Students Born in the United States
IMMUNIZATION COMPLIANCE FORM
Louisiana R.S. 17:170 – Schools of Higher Learning
Tulane University Campus Health – Uptown 504-865-5255, Downtown 504-988-6169
Upload this form and any lab reports in the Patient Portal: campushealth.tulane.edu/immunizations.
Name: Date of Birth: / /
Please Type or Print (Last) (First) (M.I.) (MM / DD / YYYY)
Tulane Splash ID #: ___ ___ ___-00-___ ___ ___ ___ Semester of Enrollment: Country of Birth United States
Tulane Email: @tulane.edu Phone: ( )
▼ This must be completed and signed by a physician or health care provider. ▼
HEALTH CARE PROVIDER:
Name (Typed or Printed) Signature
Address
Phone Date
tulane-immunization-compliance-form-domestic-4-17-2019.docx
Required Immunizations
MMR (Measles, Mumps, Rubella) - Two doses required
Two doses of MMR at least 28 days apart. First dose after
12 months of age.
OR
Positive antibody titers for measles, mumps and rubella.* Required:
Submit titers laboratory report for proof of immunization.
________/________/________
(MM / DD / YY)
MMR Dose #2 Date:
_______/________/_________
(MM / DD / YY)
OR Individual Doses (MM / DD / YY)
Measles #1: _________/__________/_________
Measles #2: _________/__________/_________
Mumps #1: _________/__________/_________
Mumps #2 : _________/__________/_________
Rubella #1: _________/__________/_________
Serologic Tests & Results (Must provide copy of lab reports.*)
Tetanus, Diphtheria, Pertussis (Tdap recommended)
**
Last dose must be within the past 10 years of start date.
Vaccine Date
**
: _________/__________/_________ (MM / DD / YY)
Must Select Type: TD or Tdap
Meningococcal – One dose required at 16 years of age or older.
Quadrivalent vaccine A, C, Y, W-135
*A dose given within the past 5 years is required for all undergraduates and
is also required by Tulane for any student in uptown on-campus housing or
fraternity/sorority housing. A booster dose is required every five years.
Vaccine Date
*
: _________/__________/_________ (MM / DD / YY)
Must Select Type: Menactra or Menveo or Nimenrix
*Last dose must be within the past 5 years.
TUBERCULOSIS QUESTIONNAIRE
SECTION ONE – Please answer the following questions:
Has the student ever had a positive TB skin test?
(If Yes, stop here. Obtain IGRA and upload lab report with this form.)
1. Has the student traveled or lived more than 6 weeks in Africa, East Europe, Asia, Middle East, or South/Central
America?
2. Has the student been vaccinated with BCG?
3. Has the student been an employee or volunteer in a prison, nursing home, homeless shelter or hospital?
4. Has the student ever had close contact with somebody ill with TB?
5. Is the student on medications that suppress the immune system?
6. Does the student have HIV?
If the answer to all of the above questions is NO, no TB testing or further action is required.
If the answer is YES to any of questions 1-6, you must obtain the PPD skin test from a health care provider. The test must be done
within the 12 months prior to beginning your classes. (Provide test results below.)
SECTION TWO – Test Results:
Tuberculin Skin Test
Positive if ≥ 10mm for questions 1, 2 or 3
OR ≥ 5mm for questions 4, 5 or 6.
Skin Test Date: ______/______/______ Date Read: ______/______/______ Result:___mm of
Induration
Interpretation: Positive Negative
(IGRA is required if PPD is positive; Chest x-ray required within the last 3 months if IGRA is positive.)
