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					TO:        Class of 2015
           UCR/UCLA Thomas Haider Program in Biomedical Sciences

FROM: Faye Dawson Brock
      Director, Instructional Support Unit
      UCR/UCLA Thomas Haider Program in
      Biomedical Sciences
      University California, Riverside
      Riverside, CA 92521-0121

The UCR/UCLA Thomas Haider Program in Biomedical Sciences requires that all medical students obtain a health
clearance. The enclosed “Health Screening Requirement Health History and Immunization/Infectious Disease
Documents” must be initiated before the first week of coursework. This includes a complete physical examination, as
well as demonstrated immunity to certain communicable diseases. We are aware that the Hepatitis B vaccine series will
require a three step process, but the first step should already be completed before instruction begins. Margie and I will
meet with you on August 2, 2011 in LA so please provide these documents at that time or send to me.

Each of the following requirements must be met in order to fulfill the UCLA School of Medicine’s mandate:
    1. Tuberculosis Skin Test (PPD/Mantoux) – within 6 months of entry to school. If your PPD is reactive
         (positive), or you have a history of a reactive PPD, a chest x-ray is required within 6 months of entry to school.

      2.   Tetanus/diphtheria – within 10 years. Exact date of vaccine must be indicated.

      3.   Measles, Mumps, Rubella – You must demonstrate immunity to Measles, Mumps and Rubella. You must
           submit proof of a laboratory blood test for the antibody against Measles, Mumps and Rubella. (Vaccines are
           not acceptable in lieu of a titer.) A copy of the Lab report must be submitted and if the MMR results are
           negative you must be immunized.

      4.   Hepatitis B – You must demonstrate immunity to Hepatitis B. If you have been vaccinated or have reason to
           believe you have natural immunity because of previous exposure, or because you lived in an area where
           Hepatitis B infection is common, you must present proof of a laboratory test for antibody to the virus (Hepatitis
           B Surface Antibody). If you are not immune to Hepatitis B you must complete a three vaccination series over a
           six month period. You are required to have the first two doses prior to Orientation. When you have
           completed the three vaccines, a Hepatitis B Surface Antibody titer must be taken and a copy of the lab
           report submitted.

      5.   Varicella – Varicella titer is required and a copy of the Lab Report must be submitted. (Vaccines are not
           acceptable in lieu of a titer.) If you are not immune to Varicella you must complete two vaccines given 30 days
           apart. The two vaccines must be completed prior to Orientation.

How to obtain a health clearance:
Plan A: You may also have the health clearance and some or all of the requirements completed at the UCR Health
Center. You are also responsible for the cost of any lab and immunization fees. You will need to schedule an
appointment at the Student Health Center and remember to take your form.

Plan B: You may choose to have the health clearance form completed by your health care provider. If you choose to
use your own health care provider, be sure to keep copies of your paperwork for yourself and hand in 1-5 above (form
and lab reports) to:

UCR – Faye Dawson Brock, Biomedical Sciences Office.
Health Screening Requirements: Immunization/Infectious Disease Status

Name:                                                        Student ID#:
Birth date:

1.      Measles Serology (required for Measles [Rubeola])
        Please specify the date and result of a blood test for Measles immunity. If the result is negative, you
        will need to get a booster vaccine and enter the date (which must be after the date of the blood test) in
        the immunization section below.
        Test Date: _______________ Result: ______positive _____negative

2.      Measles (only required if Measles [Rubeola] titer is negative)
        Please specify the date of your Measles immunizations.
        Date for Dose 1: _______________

3.      Rubella Serology (required for Rubella)
        Please specify the date and result of a blood test for Rubella immunity. If the result is negative, you
        will need to get a booster vaccine and enter the date (which must be after the date of the blood test) in
        the immunization section below.
        Test Date: _______________ Result: ______positive _____negative

4.      Rubella (only required if Rubella titer is negative)
        Please specify the date of your Rubella immunizations.
        Date for Dose 1: _______________

5.      Mumps Serology (Required for Mumps)
        Please specify the date and result of a blood test for Mumps immunity. If the result is negative, you
        will need to get a booster vaccine and enter the date (which must be after the date of the blood test) in
        the immunization section below.
        Test Date: _______________ Result: ______positive _____negative

6.      Mumps (only required if Mumps titer is negative)
        Please specify the date of your Mumps immunizations.
        Date for Dose 1: _______________

7.      Measles, Mumps, and Rubella (MMR) (satisfied requirement for Measles, Mumps, and Rubella if
        any of the titers were negative)
        Please specify the date of your MMR immunization.
        Date for Dose 1: _______________

8.      Tetanus/Diphteria/Pertussis ( Tdap) Immunizations
        Please indicate the date on which the dose was given:
        Date for Dose 1: _______________

9.      Varicella (Chicken Pox) (satisfies Professional School Varicella Immunization requirement)
        If you received individual immunizations for Varicella, please indicate the date that each dose was
        given. Two doses required.
        Date for Dose 1: _______________
        Date for Dose 2: _______________
10.     Varicella Immunity (satisfies Professional School Varicella Immunization requirement)
        If you had a blood test for Varicella, please provide the date and result:
        Test Date: _______________ Result: ______positive _____negative

11.     Hepatitis B (Professional School Hepatitis B Immunization requirement)
        Please indicate the date that each dose of Hepatitis B vaccine was given. Three doses required.
        Date for Dose 1: _______________
        Date for Dose 2: _______________
        Date for Dose 3: _______________

12.     Hepatitis B (satisfies Immunization Requirement for Hepatitis B. PLEASE NOTE: This is required
        IN ADDITION to Hepatitis B Immunization history)
        Please indicate the date and result of your Hepatitis B surface antibody titer.
        Test Date: _______________ Result: ______positive _____negative

13.     PPD (Mantoux test for Tuberculosis)
        If you had a PPD test for Tuberculosis, please record the result here.
        Date of Administration: ____________________
        Date Read: _______________ Result: ______positive _____negative
        _____________ mm Induration

14.     Chest X-ray (for Tuberculosis screening)
        If you have had a chest x-ray performed as a follow-up to a positive PPD result, please record the
        result here:
        Date of Administration: _________________ Result: ______positive ______negative


Infectious disease status reviewed and up to date _____ (check if complete)
Signature of Clinician:                                                            Date:
Print Name and Title:                                                 Telephone:
Address of Clinician:
Mail or return completed form to:
        Faye Dawson Brock
        Division of Biomedical Sciences                 This completed form needs to be in Faye’s hands and in
        1626 Statistics Building                         your file before August 2, 2011. You may not begin
        University of California, Riverside              medical school without having completed this form!
        Riverside, CA 92521-0121

				
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posted:10/12/2011
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