Student Name Eastern New Mexico University Roswell IMMUNIZATION measles

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Student Name Eastern New Mexico University Roswell IMMUNIZATION  measles Powered By Docstoc
					                                                                                             Student Name: _______________________________

                                                   Eastern New Mexico University-Roswell
                                               IMMUNIZATION/HEALTH TESTING REQUIREMENTS

The following immunizations/tests are required by the clinical agencies used by health programs at ENMU-Roswell. Each must be verified with
appropriate documentation or with a signature by a health care provider. This form and attachments (if any) must be returned to Nursing Program
on or by the first day of class.

                1.    Tetanus, Diphtheria Toxoid Combined (Td or Tdap): Immunization OR booster within the last 10 years.
                      DATE: _________________ LOT #: __________________

                      Signature/license number of health care provider: __________________________________ Date: _____________

                2. Measles, Mumps, Rubella (MMR) Vaccine:

                      Proof of TWO Immunizations if born in 1957 or later: DATE: __________________ DATE: __________________

                      Proof of ONE Immunization if born before 1957: DATE: __________________

                      Signature/license number of health care provider: __________________________ Date: ____________________

                 3. Measles, Mumps, Rubella Titers: (Titers will be needed if student does not have proof of MMR immunizations)

                      Measles immunity status: __________________________

                      Mumps immunity status: __________________________

                      Rubella Immunity Status: __________________________

                      Signature/license number of health care provider: _____________________________ Date: _________________

                 4.   Hepatitis B Vaccine and/or Titer:

                      Dose #1 DATE: _____________                                         TITER RESULTS: _____________________

                      Dose #2 DATE: _____________

                      Dose # 3 DATE: _____________

                      Signature/license number of health care provider: _____________________________ Date:_______________

            ** I decline the Hepatitis B vaccination series __________________________.Signature of Student. Date ___________
                5. Varicella (Chickenpox) Vaccine and/or Titer: Must have health care provider documentation of having had
                varicella infection, proof of two immunizations, or proof of current immunity by titer.

                      Immunity status: __________________ Titer results_____________
                                 st                                           nd
                       Vaccine: 1 immunization date: _________________ 2 immunization date:__________________

                      Signature/license number of health care provider: ______________________________ Date: ________________

                     **MARK ONE: _____IHAVE HAD CHICKENPOX.                      _____I HAVE NOT HAD CHICKENPOX
                6. Tuberculosis (PPD or tuberculin skin test)-within 90 days of start of clinical rotation:
                      Signature of Student:______________________________ Date:_______________
                      DATE: __________________ DATE READ: ________________ RESULTS: _____________

                      DATE: __________________ DATE READ: ________________ RESULTS: _____________

                      Signature/license number of health care provider: _________________________________ Date: ______________


Proof/Copy of current American Heart Association Adult, Child, and Infant CPR Certification (BLS Provider or Healthcare Provider). ENMU-
Roswell offers this certification course each semester. Attach copy of CPR certification to this form. The above information is required by some
clinical agencies and must be released to the agencies when requested. Your signature is necessary to release this information to those agencies.

Student Name (PRINT): ______________________________ Student Signature: ________________________ Date: _________________

				
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