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PA RT I: To be completed by the (Rutgers University)

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PA
RT I: To be completed by the student. Please print or type.
Last name
First name
MI
RUID or A number
School/grad year/program
DOB (month day year)
Cell phone
Email
PART II: To be completed and signed by health care provider.
Date (mo day yr) Results if applicable
MMR (Measles/Rubeola, Mumps, Rubella) vaccine
or
serologic immunity (attach lab report)
__ /__ /___ Dose 1
__ /__ /___ Dose 2
__ /__ /___
Mumps
Rubella
Immune
Non-immune
Immune Non-immune
Immune Non-immune
Meningitis ACYW
(required for ALL students under 19, first year college students in
housing, those with risk factors
1,2,
and specific travelers
3
)
with at least 1 dose since age 16
__ /__ /___
__ /__ /___
Menveo
Menactra
Menomune
Menveo Menactra Menomune
Meningitis B (required for students with risk factors
1
)
1
asplenia, sickle cell, N meningitidis lab work, complement deficiency or
complement inhibitor use
2
HIV
3
travelers to/residents of areas with endemic
meningitis
__ /__ /___
__ /__ /___
__ /__ /___
Trumenba
Bexero
Trumenba Bexero
Trumenba Bexero
Hepatitis B (if starting the series, at least one dose is required prior to
enrollment) Engerix Heplisav Twinrix
Engerix Heplisav Twinrix
or En
gerix Heplisav Twinrix
QUANTITATIVE Hep B Surface Antibody showing immunity (attach report)
__ /__ /___ Dose 1
__ /__ /___ Dose 2
__ /__ /___ Dose 3
Immune (≥10 mIU/mL) Non-immune
Tuberculosis: please review with the student to assess need for tuberculin testing. Has the student:
1. Had close contact with persons known or suspected to have active TB disease?
2. Spent more than one month OR was born in: Angola, Bangladesh, Brazil, Cambodia, China, Congo, Central
African Republic, North Korea, Congo, Ethiopia, India, Indonesia, Kenya, Lesotho, Liberia, Mozambique,
Myanmar, Namibia, Nigeria, Pakistan, Papua New Guinea, Philippines, Russia, Sierra Leone, South Africa,
Thailand, Tanzania, Vietnam, Zambia or Zimbabwe
3. Lived in or been employed by a correctional facility, long-term care facility, or homeless shelter?
4. Volunteered or worked with clients/patients at increased risk for active TB disease?
Yes No
Yes No
Yes
No
Yes
No
If the answer is YES to any of the above questions, the student is required to submit TB testing from the past 6
months (through either a PPD or TB blood test, regardless of prior BCG). Please document testing below.
Has the student had a positive PPD or TB blood test in the past? Yes No
If PPD positive (now or in the past), is the student free of TB symptoms? Yes No
PPD
Placed __ /__ /___
Read __ /__ /___
Induration ____ mm
Was the student treated? Yes No
For positive PPD: a normal chest x-ray or negative FDA approved blood test is required within
the past 6 months (attach report). For positive TB blood test: a chest x-ray is required within the
past 6 months (attach report)
TB blood test __ /__ /___
Negative Positive
Chest x-ray __ /__ /___
Normal
Findings:____________________
COVID-19 vaccine
Pfizer
Moderna
J&J
other: ____________
Pfizer Moderna J&J other: ____________
Pfizer Moderna J&J other: ____________
__ /__ /___
__ /__ /___
__ /__ /___
Healthcare provider name
Signature
Date
Revised 4.29.21
Use your Rutgers login to upload this completed and
signed form onto https://rutgers.medicatconnect.com/
Questions? email vaccine@echo.rutgers.edu
Immunization Record
Last name
First name
DOB (month day year)
RUID or A number
PART III: Additional vaccinations: Please complete or attach a legible copy. We recommend submitting
this information so we can better care for you at our health centers during your time at Rutgers.
Date (mo day yr)
Results (if applicable)
Adult Tdap Tdap Td
/ __ /
Varicella (Chicken Pox)
Varicella Dose #1
Varicella Dose #2
OR
Varicella serologic immunity (list date and attach lab report)
/ __ /
/ __ /
/ __ /
Immune
Non-immune
Annual flu (list vaccination for the current flu season)
/ __ /
Hepatitis A
/ __ /
/ __ /
Human Papilloma Virus Gardisil 4 Gardasil 9 Cervarix
Gardisil 4 Gardasil 9 Cervarix
Gardisil 4 Gardasil 9 Cervarix
/ __ /
/ __ /
/ __ /
Japanese Encephalitis
/ __ / __
/ __ /__
Pneumococcal
PCV13
PPSV23
PCV13 PPSV23
PCV13 PPSV23
PCV13 PPSV23
/ __ /
/ __ /
/ __ /
/ __ /
Polio booster
/ __ /
Rabies vaccine
/ __ /
/ __ /
/ __ /
Typhoid TyphIM Vivotif (most recent dose)
/ __ /
Yellow Fever
/ __ /
Healthcare provider
Print name
Signature
Date
Use your Rutgers login to upload this completed and
signed form onto https://rutgers.medicatconnect.com/
Questions? email vaccine@echo.rutgers.edu
Cat 4 4.29.2021
Cat 4 4.29.2021
Healthcare Provider and student checklist (REQUIRED ITEMS)
Mandatory
Health
Form
□
Students must complete an ONLINE Mandatory Health Form at https://rutgers.medicatconnect.com/
MMR
□
2 doses of Measles, Mumps, and Rubella vaccine (first dose must be after age 1)
OR
□ MMR IgG titers showing immunity – attach lab report
LabCorp test #058495 Quest Diagnostic test #85803A
Meningitis
ACYW
Meningitis
B
□
Meningitis ACYW (required for students under 19, first year college students in housing, thosewith
a
splenia, sickle cell, N meningitidis lab work, complement deficiency or complementinhibitor use,
HIV, and travelers to/residents of areas with endemic meningitis)with at least 1 dose since age 16
□ Meningitis B (required for students with asplenia, sickle cell, N meningitidis lab work, complement
de
ficiency or complement inhibitor use)
Hep B
□
Complete series of Hepatitis B vaccine (3 doses of Engerix or 2 doses of Heplisav)
OR
□ Hepatitis B Surface Antibody QUANTITATIVE titer (the result must be a number) attach lab
report
.
LabCorp test # 006530 Quest Diagnostic test # 51938W
PPD
Students are assessed for tuberculosis risk through a series of questions on the online Mandatory Health
Form (also listed on the immunization record). Students with past or current risk will need to submit
either a single PPD or FDA approved blood test. Testing must occur regardless of receiving BCG in
the past. The questions are listed in the Immunization Record.
□ PPD
• Please include date placed and date read in millimeters of induration
• For a PPD ≥10 mm now or in the past, you must submit documentation of the PPD readin
g
and a chest x-ray or FDA approved blood test within the last 6 months
OR
□ an FDA approved blood test for TB (such as Quantiferon Gold)
LabCorp test # 182873 Quest Diagnostic test # 19453
Tdap
This vaccination is highly recommended once after age 19 for everyone. If you will be spending time in a
lab or a clinical environment, it is your responsibility to obtain this vaccination.
□ Adult Tdap (tetanus/diphtheria/acellular pertussis) (Adacel/Boostrix) (one-time administration)
Varicella
Please document the student’s varicella vaccination or titer if known.
COVID-19
vaccine
Please document all doses of ACIP-approved COVID-19 vaccines.
* Students working in healthcare with two or more up-to-date annual PPDs may submit that documentation to fulfil this
requirement.
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PA RT I: To be completed by the (Rutgers University)

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Completed 23 July 2021

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