Student: __________________________________________________ SS#: ____________________________________

College: __________________________________________________ Date: ____________________________________

The following immunizations/tests are required for all visiting students. This form must accompany the application for all 
electives at MUSC.

1. RUBEOLA (Red Measles) Vaccine: (2) Live Vaccines or Titer (BOTH vaccines after 12/31/67 and age of 12 months)

 #1_____________________ (M/D/Y) #2 ______________________ (M/D/Y)   Rubeola Titer: _______________ ________________
                                                                                                                                                                                RESULTS                      DATE (M/D/Y)
2. RUBELLA (German Measles) Vacinne - Live Vaccine or Titer:

 Vaccine: ______________________ (M/D/Y)       Rubella Titer: _______________________ ________________________
                                                                                                                          RESULTS                                  DATE (M/D/Y)
3. VARICELLA (Chicken Pox) Must provide ONE of the following:

     a) History of disease (DATE): ______________________________________________
     b) If you have NEVER had the disease or are unsure, either:

     Varicella Titer: _______________________ __________________________________
                                      RESULTS                            DATE (M/D/Y)
OR
     c) Varifax Vaccine: #1 _____________________ #2 ____________________________
                                            DATE (M/D/Y)                           DATE (M/D/Y)
4. TETANUS Vaccine - Must be within the past 10 years: _________________________
                                                                                                       DATE (M/D/Y)
5. INTRADERMAL TB SKIN (IPPD) TEST: Must be within (1) year from end of the rotation dates (i.e. Last TB Test 
    12/4/98 and rotation beings 1/3/00 = not acceptable) Tine test is not acceptable.

     Date Given: ___________ Date Read: ___________ Results: _____________mm

     IF above RB skin test is equal to of less than 10mm, a CHEST X-RAY is required:

     Date of X-Ray: ____________ Results: ____________________ (copy of report required)

     INH Treatment: YES __________ NO __________

     IF history of PREVIOUSLY POSITIVE TB SKIN TEST, a CHEST X-RAY is required after documentation of PPD(+):

     Date of X-Ray: ____________ Results: ____________________(copy of report required)

6.HEPATITIS B Vaccine series required:

    { } Recombivax HB { } Energix-B { } Heptavax
     DATES: #1 ______________ #2 _______________ #3 _______________
     Hepatitus B Titer Results (if available) ________________ DATE ______________

_________________________________________________________________________ _____________________
I certify this information to be correct: Signature of Physician or Student Health Official                        Date