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
CLINIC STAMP
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.
MMR Dose #1 Date:
________/________/________
(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: _________/__________/_________
OR
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
MeningococcalOne 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 ONEPlease 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.)
Yes
No
1. Has the student traveled or lived more than 6 weeks in Africa, East Europe, Asia, Middle East, or South/Central
America?
Yes
No
2. Has the student been vaccinated with BCG?
Yes
No
3. Has the student been an employee or volunteer in a prison, nursing home, homeless shelter or hospital?
Yes
No
4. Has the student ever had close contact with somebody ill with TB?
Yes
No
5. Is the student on medications that suppress the immune system?
Yes
No
6. Does the student have HIV?
Yes
No
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.)
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.
tulane-immunization-compliance-form-domestic-4-17-2019.docx
Other Immunizations (Recommended, Not required)
Bexsero
Meningococcal B
Two doses
Dose #1: ________/________/________ Dose #2: _________/_________/________
(MM / DD / YY)
Trumenba
Meningococcal B
Three doses
Dose #1: ________/________/________ Dose #2: _________/_________/________ Dose #3: ________/________/________
(MM / DD / YY)
Gardasil (HPV)
Three doses
Dose #1: ________/________/________ Dose #2: _________/_________/________ Dose #3: ________/________/________
(MM / DD / YY)
Hepatitis B
Three-dose vaccines: Energix-
B, Recombivax, Twinrix
Two-dose vaccine: Heplisav-B
Dose #1: ________/________/________ Dose #2: _________/_________/________ Dose #3: ________/________/________
(MM / DD / YY)
Dose #1: ________/________/________ Dose #2: _________/_________/________
(MM / DD / YY)
Varicella (Chicken Pox)
Two doses
Dose #1: ________/________/________ Dose #2: _________/_________/________
(MM / DD / YY)
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.
tulane-immunization-compliance-form-domestic-4-17-2019.docx
How to Submit
1) Make sure your health provider completes and signs the form and provides copies of applicable lab reports. All lab
reports must indicate your name and date of birth.
2) Scan these documents. NOTE: Your files can be no larger than 4 MB. (Scan in black and white or at a setting of 150
DPI to achieve a smaller file.)
3) Visit our website at campushealth.tulane.edu/immunizations.
4) Log on to the Patient Portal using your Tulane log-on information (your email address without the @tulane.edu and
your email password).
It may take up to three business days after you receive your Tulane email account before you can access the Patient Portal. If you
still cannot log in to the Patient Portal after three days, please contact the immunization office for assistance at
immunizations@tulane.edu.
5) Choose Immunizations and Enter Dates. Fill in all the dates and information copied directly from your form. When
finished, clickSubmit”.
6) Next, use the Upload Documents link to upload your scanned copy of the completed form along with any necessary
lab reports.
7) Once your form is uploaded, it may take up to five business days for the form to be reviewed and verified. Check your
Tulane email regularly for notification of secure messages from the Health Center.
8) You will receive a secure message via the Patient Portal notifying you whether your records are either
() in compliance which allows you to register for classes or
() out of compliance which means you cannot register for classes until you upload the additional records specified
via secure message.
9) All communication regarding your immunization records is private and visible only via the Patient Portal. You will
receive a secure message notification in your Tulane email directing you to the Patient Portal. You should submit
health information only via the Patient Portal and never by email.
10) Tulane must have evidence of a student’s compliance with University policy and Louisiana law for immunizations.
Failure to meet these requirements will result in an Enrollment Hold being placed on your student account, which will
bar you from dropping or adding classes and/or enrolling for classes for the next semester.
Students born in the United States who want to request an exemption/waiver from immunizations, visit
campushealth.tulane.edu/immunizations for instructions.
For assistance, please email
immunizations@tulane.edu
.