Boston University Medical Campus



Boston University Immunization Form Last Name:First Name:Middle Initial: DOB: Street Address:Medical School: City: Cell Phone: State: Primary Email:ZIP Code:MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose of Rubella; or serologic proof of immunity for Measles, Mumps and/or RubellaOption1VaccineDateMMR-2 doses of MMR vaccineMMR Dose #1___/___/____MMR Dose #2___/___/____Option 2 Vaccine or TestDateMeasles-2 doses of vaccine or positive serologyMeasles Vaccine Dose #1___/___/_____Measles Vaccine Dose #2___/___/_____Serologic Immunity (IgG, antibodies, titer)___/___/_____ Copy AttachedMumps-2 doses of vaccine or positive serologyMumps Vaccine Dose #1___/___/_____Mumps Vaccine Dose #2___/___/_____Serologic Immunity (IgG, antibodies, titer)___/___/_____ Copy AttachedRubella-1 dose of vaccine or positive serologyRubella Vaccine___/___/_____Serologic Immunity (IgG, antibodies, titer)___/___/_____ Copy AttachedHepatitis B Vaccination --3 doses of vaccine followed by a QUANTITATIVE Hepatitis B Surface Antibody (titer) preferably drawn 4-8 weeks after 3rd dose. If negative, complete a second Hepatitis B series followed by a repeat titer. If Hepatitis B Surface Antibody is negative after a secondary series, additional testing including Hepatitis B Surface Antigen should be performed. See: for more information. Documentation of Chronic Active Hepatitis B is for rotation assignments and counseling purposes only. Primary Hepatitis B SeriesDateHepatitis B Vaccine Dose #1___/___/_____Hepatitis B Vaccine Dose #2___/___/_____Hepatitis B Vaccine Dose #3___/___/_____QUANTITATIVE Hep B Surface Antibody___/___/_____Result_______ mIU/ml Copy AttachedSecondary Hepatitis B Series(If no response to primary series)Hepatitis B Vaccine Dose #4___/___/_____Hepatitis B Vaccine Dose #5___/___/_____Hepatitis B Vaccine Dose #6___/___/_____QUANTITATIVE Hep B Surface Antibody___/___/_____Result_______ mIU/ml Copy AttachedHepatitis B Vaccine Non-responder(If Hepatitis B Surface Antibody Negative after Primary and Secondary Series)Hepatitis B Surface Antigen (if 2nd titer negative)___/___/_____ Copy AttachedHepatitis B Core Antibody (if 2nd titer negative )___/___/_____ Copy AttachedChronic Active Hepatitis BHepatitis B Surface Antigen ___/___/_____ Copy AttachedHepatitis B Viral Load___/___/_____ Copy AttachedTetanus-diphtheria-pertussis – One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide date of last Td and Tdap DateTdap Vaccine (Adacel, Boostrix, etc)___/___/_____Td Vaccine (if more than 10 years since last Tdap)___/___/_____TUBERCULOSIS SCREENING – Results of last (2) TSTs (PPDs) are required regardless of prior BCG status. If you have a history of a positive TST (PPD)>10mm please supply information regarding any evaluation and/or treatment below. You only need to complete ONE section. Skin test results should not expire during proposed elective rotation datesormust be updated with the receiving institution prior to rotation.Tuberculin Screening History189865-466090000Please complete one TB section onlySection ADate PlacedDate ReadReadingInterpretationNegative Skin Test HistoryYou are required to have two skin tests: 1) one within 12 months of the start date of your elective; and 2) one within 12 weeks of the start date of your elective.TST #1___/___/_______/___/________ mm Pos Neg EquivTST #2___/___/_______/___/________mm Pos Neg EquivTST #3___/___/_______/___/________ mm Pos Neg EquivBoston Medical Center does not accept any IGRA tests for TB screening (e.g., Quantiferon-TB Gold or T-SPOT.TB). If you are unable to get a TB test in your home country, you may receive a TB test at Boston Medical Center upon arrival. Keep in mind that TB test results are read 48-72 hours after they are planted. Students may not start on the wards until the skin test is read. The fee is $30 for a TB test.Section BDate PlacedDate ReadReadingInterpretation History of Latent Tuberculosis, Positive Skin Test or Positive Blood Test Positive TST ___/___/_______/___/________ mmDateResultChest X-ray ___/___/____ Copy AttachedProphylactic Medications for latent TB taken? Yes NoTotal Duration of prophylaxis?_____ MonthsDate of Last Annual TB Symptom Questionnaire (if applicable)___/___/_____ Copy AttachedSection CDateHistory of ActiveTuberculosisDate of Diagnosis___/___/___Date of Treatment Completed___/___/____ Copy AttachedDate of Last Annual TB Symptom Questionnaire (if applicable)___/___/____ Copy AttachedDate of Last Chest X-ray___/___/____ Copy AttachedVaricella (Chicken Pox) -2 doses of vaccine or positive serologyDateVaricella Vaccine #1___/___/_____Varicella Vaccine #2___/___/_____Serologic Immunity (IgG, antibodies, titer)___/___/_____ Copy AttachedInfluenza Vaccine --1 dose annually required September thru May. Boston Medical Center can administer flu shot if you cannot obtain one in your home country. The fee is $15 for a flu shot.Flu Vaccine___/___/____ Copy AttachedFlu Vaccine___/___/____ Copy AttachedAdditional Information: MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER OR INSTITUTIONAL REPRESENTATIVE:Authorized Signature:Date: ___/___/____Printed Name:Office Use OnlyTitle:Address Line 1: Address Line 2:City: State:Zip: Phone:(____) ______-____________ Ext: _______Fax:(____) ______-____________ Email Contact: ................
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