Fillable USC or VIP ID Name TO BE COMPLETED (University of South Carolina - Aiken)

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USC or VIP ID Name TO BE COMPLETED (University of South Carolina - Aiken)

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THIS FORM MUST BE IN ENGLISH
AND RETURNED BEFORE ORIENTATION TO:
University of South Carolina Aiken
Enrollment Management, Box 35
471 University Parkway
Aiken, SC 29801
Fax: (803) 641-3727 Email: enroll@usca.edu
TO BE COMPLETED BY STUDENT
Name
USC or VIP ID
Last First Middle
Address Date of Birth / /
Street/P.O. Box
Mo Day Yr
Sex ☐ M ☐ F
City State Zip Code
a.
Dose 1 given at age 12 months or later ………………….……..…………………….... #1
/
Mo Day Yr
Dose 2 give at least 28 days after the first dose…..................................................... #2
Mo Day Yr
b. Laboratory/serologic evidence of immunity (attach a copy of positive titer with date)
c. Exemption: I was born before 1957, and therefore am exempt from this requirement
2. Required Immunization For Students Living On Campus
a. Meningitis vaccination received within the past five years.
Menactra or Menveo Vaccine Lot # __________ Administration Date / /
Mo Day Yr
b. I have read the information provided on page 2 & educated myself on the risks of Meningococcal Disease.
choose NOT to be vaccinated with Menactra or Menveo Immunization/Vaccine.
Signature
(parent signs if student is under 18 )
Date:
*To be signed by Health Care Provider Signature or Stamp
required
for processing unless records are attached on separate page(s).
Name: _______Date:
(Please Print)
Address:
Street/P.O. Box
City State Zip Code
Phone: (
)
Signature:
Revised 6/20
See reverse side for additional immunization required for international students and recommended immunizations for all students
1. Required Immunizations for ALL Students
M.M.R. (Measles, Mumps, Rubella): Two (2) doses are required for ALL students born in 1957 or later.
Email
Telephone ( )
Admitted for: ☐ Fall ☐ Spring ☐ Summer Year
Check one: ☐ Undergraduate ☐ Graduate ☐ Nondegree
IMPORTANT: a) The bottom section of this form must be completed & signed by the student's health care provider, unless b) A
legal photocopy of the student’s immunization/vaccine records may be attached (as long as it is verified with a doctor’s signature
or stamp, or by a clinic or health department’s stamp). c) If vaccination records or provider-verified dates are unavailable, a
positive blood titer may be attached which proves the student's immunity due to the specified antibodies.
*Please see the next page of this form for screening requirements for international students and for recommended
immunizations for all students.
/
/ /
3. Required Screening For International Students ONLY
1. Have you ever had a positive TB skin test?..................................................YES ________ NO ________
2. Have you ever had close contact with anyone who was sick with TB?.........YES ________ NO ________
3. Have you ever been vaccinated with BCG?..................................................YES ________ NO ________
4. Are you are a member of a high-risk group¹?................................................YES ________ NO ________
5. If No (to #4), you are not required to have a TB screening. If YES, you are required to have a TB screening.
BCG vaccine is not acceptable to meet this requirement.
a. Tuberculin Skin Test:
Date Given:
/
Date Read:
/
Mo Day Yr Mo Day Yr
Result: mm (Record actual mm of induration, transverse diameter; if no induration, write “0”)
Positive Negative (Interpretation, based on mm of induration as well as risk factors)
b. Chest X-ray (required if tuberculin skin test is positive)
Date of chest x-ray
Normal _______ Abnormal
Mo Day Yr
Chest X-ray Findings (if abnormal)____________________________________________
Recommended Immunizations for All Students
Although they are not yet required, meningococcal and hepatitis B vaccinations are strongly recommended based on
recommendations from the Centers for Disease Control (CDC) and the American College Health Association. These recommendations
are made based on recent studies showing that college students, particularly freshmen living in residence halls, have a six-times
greater risk for meningitis and an increased risk of hepatitis B than the general population.
Meningococcal disease is a rare but potentially fatal bacterial infection that occurs in one of two forms, either as meningococcal
Meningitis (a bacterial infection that causes inammation of the brain and spinal cord) or meningococcemia (a bacterial infection of
the blood). Meningitis is difcult to diagnose because of its u-like symptoms. It progresses very quickly and may result in permanent
disability or death within a matter of hours of the rst symptoms. Transmission of the disease occurs from person to person through
respiratory or oral secretions. Cases of meningitis among teens and young adults 15 to 24 years of age have more than doubled since
1991. Ask about the Menactra vaccine for protection against Meningitis & Meningococcemia.
Hepatitis B virus (HBV) exposure can result in a serious disease that attacks the liver. There is no cure for this disease. The CDC
estimates that some 80,000 new cases occur in the US each year and approximately 500 people die from chronic liver problems
related to hepatitis disease annually. HBV is a blood-borne disease and is commonly spread by contact with infected blood, needles or
other sharps, or by having sex with an infected person. The best protection against HBV is immunization.
In addition, it is recommended that students receive two varicella (chicken pox) vaccines if they have never had chicken pox or receive
a second varicella vaccine if they have only received one previously. It is also recommended that female students receive the series of
three Gardasil vaccines to protect them from cervical cancer.
For more detailed information, visit the Centers for Disease Control & Prevention web site at www.cdc.gov or the American College
Health Association website at www.acha.org. Consult with your family physician, local Health Department and your Student Health
Center for vaccine information.
¹ Categories of high risk students include those students who have arrived within the past 5 years from countries where TB is endemic. It is easier to identify
countries of low rather than high TB prevalence. Therefore, students should undergo TB screening if they have arrived from countries EXCEPT those on the
following list: Canada, Jamaica, Saint Kitts and Nevis, Saint Lucia, USA Virgin Islands (USA), Belgium, Denmark, Finland, France, Germany, Greece, Iceland,
Ireland, Italy, Liechtenstein, Luxembourg, Malta, Monaco, Netherlands, Norway, San Marino, Sweden, Switzerland, United Kingdom, American Samoa, Australia
or New Zealand.
Revised 6/20
/
/
/ /
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USC or VIP ID Name TO BE COMPLETED (University of South Carolina - Aiken)

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Completed 24 July 2020

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