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					UNIVERSITY COLLEGE LONDON MEDICAL SCHOOL
Medical Student Administration



Application for Erasmus Study
Section 4 – Health and Immunisation
Verification
Section 4a - To be completed and signed by the home institution.
All immunisations listed are required for study at UCL Medical School and affiliated hospitals.
All blood tests required for health clearance must be taken in a CPA accredited laboratory in the UK and must be
identity validated.

Student Surname/Family name                                           Forenames

Date of birth                                                         Medical School Name

                                                                                                        Date day/month/year
POSITIVE SEROLOGICAL TEST FOR IMMUNITY TO                             Positive MEASLES titre            …………./………../…….
MEASLES, RUBELLA AND MUMPS
                                                                      Positive MUMPS titre              …………./………../…….
*Copy of laboratory report must be attached
                                                                      Positive RUBELLA titre            …………./………../…….
TETANUS-DIPHTHERIA - POLIO BOOSTER                                    TD Booster                        …………./………../…….

* If given separately, each must be recorded separately               Polio                             …………./………../…….

                                                                      Tetanus                           …………./………../…….

                                                                      Diphtheria                        …………./………../…….
                                                                                                         st
HEPATITIS B                                                           Hepatitis B vaccination course:   1 ………./………../…….
                                                                                                        2nd…………./………../…….
*Copy of Hep B surface antibody titre result within the past 1 year                                     3rd…………./………../…….
must be attached, whether positive or negative                                                          Booster………/……./……..
Students with evidence of infection are not able to perform           Blood results:                    HBsAb : …………IU/L
exposure prone procedures                                                                               HBsAg Detected/not detected
                                                                                                        HBcAb Detected/not detected
TUBERCULIN SKIN TEST WITHIN 2 YEARS                                   Result:                           …………./………../…….

BCG vaccine                                                           Result                            …………./………../…….
Chest x-ray if strongly positive skin test or positive TB
(*chest x-ray report must be attached)                                                                  …………./………../…….

If unable to provide evidence of immunity to TB, student may not
be fit to do respiratory medicine and should avoid contact with
infectious TB patients
CHICKENPOX (VARICELLA) IMMUNITY

i) A POSITIVE SEROLOGICAL TEST FOR IMMUNITY as                        Positive Varicella titre          …………./………../…….
evidence of previous infection *Report must be attached               OR
OR
Ii). VACCINATION DOCUMENTATION                                        Course of vaccination:            1st ……/……./……………..
                                                                                                        2d…../……/………………
HEPATITIS C                                                           Hepatitis C antibodies            …………./………../…….
*Copy of Hepatitis C antibody titre result within the past 1 year
must be attached, whether positive or negative                                                          Detected/not detected
HIV                                                                   HIV 1 & 2 antibodies              …………./………../…….
*Copy of HIV antibody titre result within the past 1 year must be
attached, whether positive or negative                                                                  Detected/not detected

I confirm that the above immunisations have been completed by the above named student

Name of authorised signatory (in block capitals or type):

Position: (in block capitals or type):

Signature:                                                                                   Stamp:

Date:                                                                                                               Page 1 of 2
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Section 4b Health and Immunisation Verification

To be completed by the student

Vaccination Record

   Vaccination                             Dates                           Vaccination                      Dates
Tetanus               1               2            3      Rubella (Life)
(Every 10 Years)
Polio                                                     Measles (Life)
(Every 10 Years)
Diphtheria                                                Mumps (Life)
(Every 10 Years)
Hepatitis B                                               MMR (Life)
(3-5 years)
Hepatitis B                                               TB status
boosters                                                  BCG Scar present?          YES/NO
Meningitis C                                              Mantoux test
conjugate or
ACWY conjugate
(3-5 years)

Health declaration

Do you have any of the following:

A cough which has lasted for more than 3 weeks?           YES                                      NO
Unexplained weight loss?                                  YES                                      NO
Unexplained fever?                                        YES                                      NO

Have you had TB or been in recent contact with open TB?   YES                                      NO


I declare that the information given above is accurate and true to the best of my knowledge and belief.

Name of student:

Student Signature:


Date:




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