The purpose of this web guide is to assist Academic Health Center students in completing the Student Immunization Record.  

Clicking or selecting the available links provides information about each section of the form and explains how to obtain the information necessary to complete the form.  Use this web guide as a reference to ensure that the form you submit to Boynton Health Services has been filled out completely and correctly. 

You may be wondering why, as students of the Academic Health Center, your vaccination requirements are different from the general public. Health care professionals are at a significantly higher risk for infectious disease. Because you may be spending time in patient care areas there is potential for exposure to infectious disease.  Vaccination requirements are more stringent for health care professionals to protect them from contracting infectious diseases.

University of Minnesota — Academic Health Center — Student Immunization Record

Last Name, First Name, MI

 

 

 

Birth Date

 

 

Month  /  Day  /  Year

Student ID#

 

 

New students see admission letter for ID#

 

 

Street Address

 

 

 

Return completed form to

     Boynton Health Service

College or School (If Resident, use “GME”)

City, State, ZIP

 

 

     410 Church Street

     Minneapolis, MN 55455

Questions?  Call 612-625-3222

Degree Program or Residency/Fellowship

 

According to OSHA regulations, CDC guidelines, and Academic Health Center (AHC) policy, all AHC students are required to have a health clearance as a condition of enrollment.  This information must be completed in order to participate in classes or patient care in the AHC.

 

This form must be completed and submitted with the proper signatures to Boynton Health Service.  It will become part of your official medical record.  After you have submitted the form, you will receive written confirmation of your “clearance” to enroll in classes and clinical experiences in the AHC and affiliated sites.  You will also receive notification of any parts that are incomplete or unacceptable and instructions on how to proceed. 

 

Boynton Health Service does not place or remove holds for AHC students.  Each of the AHC schools is responsible for insuring that students are “cleared” through this process, and Boynton facilitates this process for the schools.  It is the student’s responsibility to achieve immunization clearance.  Keep a copy of this form and any other documentation for your records.  You may submit multiple copies of this form, each documenting different requirements (if you have your first Hep B immunization now, you should submit the form now and then submit another form after the second and third immunizations).  In addition, once you have been “cleared”, you must use this form for your annual Mantoux test (one-step) in order to be cleared each year. This form may be downloaded from the Boynton website: 

 

Required Immunization
Click on each type of disease names below to obtain information about the vaccine and its importance.

# Dates Immunizations Received  OR

**Antibody Titre

Provider Signature and Date

Must be MD, DO, RNC, PA, NP, or RN

(May NOT be student or parent)
Note: All vaccinations are available Thimerosal Free # Click on the Dosage links for each vaccination to obtain information regarding the dose schedule. ** Click on each titre links below to obtain infomation about the appropriateness for a titre to suggest immunity.

Hepatitis B (Hep B)

Report 3 doses or titre results

 

Dose 1 Date

 

Dose 2  Date

Dose 3 Date

Learn more about Hep B titre

                             /    /

                                   MM   DD   YYYY

Varicella (Chicken Pox)

Report 2 doses, OR self reported disease history,  OR titre results

Dose 1 Date

 

Dose 2  Date

Self report of disease

Y/N

Learn more about Varicella titre

                             /    /

                                   MM   DD   YYYY

Measles (Rubella)

Report 2 doses after age 12 months or titre results

Dose 1 Date

Dose 2  Date

 

Learn more about Measles titre

                             /    /

                                   MM   DD   YYYY

Mumps

Report 1-2 doses after age 12 months or titre result (only one dose required)

Dose 1 Date

Dose 2  Date

Learn more about Mumps titre

                            /    /

                                   MM   DD   YYYY

Rubella (German Measles)

Report 1-2 doses after age 12 months or titre results (only one dose required)

Dose 1 Date

Dose 2 Date

Learn more about Rubella titre

                            /    /

                                   MM   DD   YYYY

Tetanus/Diptheria (Td)

Report most current dose (within 10 years)

Dose  Date

 

 

 

                            /    /

                                   MM   DD   YYYY

Required TST
(Tuberculin Skin Test)
(2-step Mantoux)

Date

Induration

Date

Induration

Provider Signature and Date

Report any TWO TST Tests applied more than one week apart and within one year (required once).

Step 1  
Date

 

               mm

Step 2 
Date

 

               mm

                               /    /

                                   MM   DD   YYYY

Report most current TST test only if more recent than 2-step test (required if last TST test is more than 1 year old).
What this means

TST    Date

 

               mm

 

 

                               /    /

                                   MM   DD   YYYY

For any POSITIVE TST test, provider must document steps taken (chest x-ray etc.):

 

 

 

 

Sign and Date

 

 

Medical Exemptions.  Provider must document medical conditions that preclude that administration of a required vaccine or test. 

Explanation of exemption:

 

 

 

 

Sign and Date