_INFECTION CONTROL POLICY AND PROCEDURE MANUAL



Student Communicable Disease Immunity Screening Guide

This is a guide outlining the immunization requirements for students at Essentia Health. All immunizations must be current through the duration of the student’s clinical experience. NOTE: If your program completes and attests to the Essentia Student Tracker Worksheet, individual immunization records do not need to be submitted to us, however, immunization records must be readily available when requested by Essentia Health.

|Required Immunity |

|Disease |The above named person has documentation of: ( ( all items that apply) |Date |

|Measles | A positive antibody test for measles | |

| | Two (2) doses of measles or a measles/mumps/ rubella (MMR) vaccine received after 1st birthday | |

|Mumps | A positive antibody test for mumps | |

| | Two (2) doses of Mumps or a measles/mumps/ rubella (MMR) Vaccine received after 1st birthday | |

| | A positive antibody test for rubella | |

|Rubella | | |

| | One (1)dose of rubella or a measles/mumps/ rubella (MMR) vaccine received after 1st birthday | |

|Pertussis | One dose of tetanus, diphtheria, pertussis (Tdap) vaccine | |

| |Exceptions: Volunteers who work in patient care areas for less than 8 hours per week. | |

| |NOTE: Tdap is not the same as the other vaccines containing some or even all of the vaccine components (D-T-A-P)| |

| |such as DTap, Td, or DT. | |

|Varicella (Chickenpox) | Physician diagnosed varicella or herpes zoster | |

| | A positive antibody test for chickenpox (varicella zoster) | |

| | Two (2) doses of Varivax (Chickenpox Vaccine) | |

| | Evidence of negative tuberculosis screening within the past 12 months (( method ) |Date |

| | | |

| | | |

| | | |

|Tuberculosis (TB) | | |

| | A negative Tuberculin Skin Test (TST) performed within the past 12 months |Date: |

| |NOTE: TST is another name for PPD or Mantoux test |induration: |

| |If this is the first test for this person, or if it has been more than 12 months since the person had a negative|______mm |

| |TST, a two- step test is required. If the first TST is negative, the second TST must be administered 1-3 weeks | |

| |after the first test is read. | |

| | OR a negative Quantiferon-TB (QTB ) blood test within the past 12 months | |

| | OR IF history of positive TST OR QUANTIFERON-TB* Test |

| | medical clearance by provider including a chest X-ray within the past 12 months. | |

| |If this box is checked, attach a copy of the most recent chest x-ray and medical evaluation / treatment. | |

| |*Individuals with a past positive TST or QTB test who do not have signs/symptoms of active TB disease may begin | |

| |assigned job pending further medical evaluation (e.g. chest x-ray) by Employee Health. | |

|Hepatitis B | Laboratory evidence of antibodies to Hepatitis B (positive hepatitis B surface | |

|Not required of student |antibody test following vaccine series or natural disease) | |

|experience is not in a clinical| | |

|setting | | |

| | If Hepatitis B immunization series has been started or completed and antibody | |

| |testing not completed, please provide dates of immunization | |

| | Completed Hepatitis B immunization declination form if student declines | |

|Recommended, not mandatory |Date |

|Influenza - annual | 1 dose of influenza vaccine for current influenza season | |

|October 1 thru March 31 | | |

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