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					    Revised 5/06

                           HEALTH IMMUNIZATION RECORD FOR WEB-BASED STUDENTS

Name _________________________________                               _______________________________
                    Last                                                           First

Address _______________________________________________________________________________
                      Street                City                  State         Zip

Date of Entry ___ / ___       Date of Birth ___ / ___ / ___        Social Security Number ____- ___ - ___

School -           SHRP _____                Program ____________________

TO BE COMPLETED AND SIGNED BY YOU OR YOUR HEALTH CARE PROVIDER (all items must be completed).

A. M.M.R. (Measles, Mumps, Rubella)
    1. Dose 1 given at 12 months after birth or later and Dose 2 after 1980……………. 1. ___/___/___            2. ___/___/___
                                                                                      M D Y                     M D Y
OR INDIVIDUAL MMR AS SPECIFIED IN B,C,D

B. MEASLES (Rubeola) (2 Doses of Live Vaccine Required)
   1. Dose 1 of live vaccine at 12 months after birth or later and Dose 2 after 1980…… 1. ___/___/___ 2. ___/___/___
OR                                                                                         M D     Y       M D Y
   2. Serologic immunity. Specify date (attach results) ………………………………………………….                         ___/___/___
                                                                                                       M D Y
C. RUBELLA (German Measles)
   1. Live vaccine at 12 months after birth or later…………………………………………………………                           ___/___/___
OR                                                                                                     M D Y
   2. Serologic immunity. Specify date (attach results) …………………………………………………..                        ___/___/___
                                                                                                       M D Y
D. MUMPS
   1. Live vaccine at 12 months after birth or later…………………………………………………………                           ___/___/___
OR                                                                                                     M D Y
   2. Serologic immunity. Specify date (attach results)……………………………………………………                          ___/___/___
                                                                                                       M D     Y
E. TUBERCULOSIS (PPD required regardless of prior BCG)
   1. PPD (2 STEP) within the past 3 months. Result #1: _____ mm induration (horizontal diamet er). Date read: ___/___/___
                                                                                                                 M D Y
      If Result #1 <10mm, PPD #2 must be done 1-3 weeks later. Result#2: _____ mm induration (horizontal diameter).. ___/___/___
                                                                                                                      M D Y
   2. All PPD’s <10mm Date: _____ mm induration: Was INH taken?: Yes ___ No ___ How long? ___

    3. If 10mm, or greater, chest X-ra y required (attach report). X-ra y result: Normal ___   Abnormal ___ Date: ________________

F. HEPATITIS B – recommended not required

G. VARICELLA (Chicken Pox)
   1. Immunized (Variva x)……………………………………………………………………1. ___/___/___                                       2. ___/___/___
OR                                                                     M D Y                                 M D Y
   2. Serologic immunity. Specify date (attach results) ……………………………………………………                                ___/___/___
OR                                                                                                           M D Y
   3. Health care provider documented clinical varicella……………………………………………………                                ___/___/___
                                                                                                             M D Y
Print Name ________________________________________
Signature _________________________________________
Date _____________________________________________

                   Return to: Office of Enrollment Services
                              65 Bergen Street, Room 149, Newark, NJ 07101
                              Phone : (973) 972-5454 Fax: (973) 972-7463
D
Dear Student Enrolled in a Web-based Program:

       The UMDNJ-SHRP promotes the health of our students through a comprehensive
immunization and health policy. As a student attending UMDNJ from a distance you are
required to submit medical documentation of your immunization. You may complete the
submission yourself or have a health care provider complete. Please note if you are taking
any classes that require patient/client contact, you will need to supply medical documentation
based on our standard immunization and health policy prior to the class, see website:
www.umdnj.edu/oppmweb/policies/content.html and click on “Student Affairs”.

      Please complete the attached immunization form before enrolling in your first course.
Please return the completed form as soon as possible but no later than two weeks before starting the
semester to:
                          Office of Enrollment Services
                          School of Health Related Professions
                          65 Bergen Street
                          Newark, New Jersey 07107-3001

Failure to submit the form may result in the inability to register in future semesters.

                                                  Sincerely,



                                                  Brian Lewis, Manager
                                                  Enrollment Services
A&B

Dear new student,

Congratulations on your acceptance!

We look forward to a “healthy” experience for you here at the University of Medicine and Dentistry
of New Jersey, School of Health Related Professions.

In order to comply with UMDNJ immunization and health policy for students, you will need to do
the following:

      Read through all forms now
      Have your health care provider document required immunizations on the enclosed form only
      Undergo a history review and physical exam, not more than six months prior to the start of
       school
      Complete the “Hepatitis B Record” (Only Required for Dental Assisting & Hygiene, Nurse
       Midwifery, Respiratory Care and Physician Assistant)
      Have a “two step” PPD test placed and read not more than three months prior to the start
       of school
      Have your health care provider sign both forms
      Complete Meningitis Response Form

Any costs incurred related to these requirements are your responsibility.

The complete UMDNJ “Student Immunization & Health Requirements” can be found at
www.umdnj.edu/oppmweb/policies/contents.html and click on “Student Affairs”.

Please return these completed forms as soon as possible but no later than two weeks before starting
the semester to:
                    Student Health Services
                    90 Bergen Street
                    DOC – 1750
                    Newark, NJ 07103-2499

Failure to submit the completed forms by the specified date to achieve compliance with UMDNJ -
SHRP policy may result in a delay in your start of school. Thank you.

Sincerely,



Medical Director
C
Dear new student,

Congratulations on your acceptance!

We look forward to a “healthy” experience for you here at the University of Medicine and Dentistry
of New Jersey, School of Health Related Professions.

In order to comply with UMDNJ immunization and health policy for students, you will need to do
the following:

      Read through all forms now
      Have your health care provider document required immunizations on the enclosed form only
      Undergo a history review and physical exam, not more than six months prior to the start of
       school
      Have a “two step” PPD test placed and read not more than three months prior to the start
       of school
      Have your health care provider sign both forms
      Complete Meningitis Response Form

You are entering an academic program with no required patient/client contact and no contact
with blood or body fluids. Therefore, you are not required to have the Hepatitis B immunizations
but we recommend obtaining the immunization. You are required to submit all other forms.

Any costs incurred related to these requirements are your responsibility.

The complete UMDNJ “Student Immunization & Health Requirements” can be found at
www.umdnj.edu/oppmweb/policies/contents.html and click on “Student Affairs”.

Please return these completed forms as soon as possible but no later than two weeks before starting
the semester to:

                           Student Health Services
                           90 Bergen Street
                           DOC – 1750
                           Newark, New Jersey 07103-2499

Failure to submit the completed forms by the specified date to achieve compliance with UMDNJ
policy may result in a delay in your start of school. Thank you.

                                                       Sincerely,


                                                       Medical Director
                      Immunization Requirements by Program Categories

A     (All including Hepatitis B antibody)

Dental Assisting                                 DA04, DAU4, DAB4
Dental Hygiene                                   DHB3, DHE3, DH03
Nurse Midwifery                                  NM02
Physician Assistant                              PA05
Respiratory Care                                 RTN2, RTN3, RTS3


B     (All except Hepatitis B antibody)

Coordinated Program                              HST3/HS03
Cytotechnology                                   CY02, CY03
Dietetic Internship                              DI02
Diagnostic Medical Sonography                    DMS2
Diagnostic Imaging Technologies                  DT02
Medical Technology                               MT02, MT03
Nuclear Medical Technology                       NMT2
M.S. - Physical Therapy                          PTS3
Doctorate of Physical Therapy                    PTP5, PTE5
Psychiatric Rehabilitation – (AS/BS)             PRF3, PR03, PRU3, PSF3, PSR3
Toxicology                                       TX02, TX03
Vascular Technology                              VT02
Allied Health Technologies                       AHT3

C     (All except Hepatitis B antibody) Hepatitis B recommended

Post – Professional DPT                          PTL5, PTU5
BA – Biology                                     BY01
Biomedical Informatics(MS/Ph.D.)                 BI05, BIP5
Health Care Informatics                          HI02
Psychiatric Rehabilitation (MS/Ph.D.)            PSR5, PRP5
Rehabilitation Counseling                        PRC5
*Web based program – student will be on campus

D     (Web-based – not on campus)

M.S. – Clinical Nutrition                        CN05
Doctorate of Clinical Nutrition                  CNP5
BSHS (except Coordinated Program)                HS03/HST3
M.S. – Health Sciences                           MHS5
Ph.D. – Health Sciences                          HSP5
M.S. – Health Systems                            MSS5

				
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