Part I

Last Name______________________________   First Name_________________________________  Date of Birth_____________


Address_________________________________  City__________________________ State_______________  Zip_____________ 


Part II- To be completed by Health Care Provider

M.M.R. (Measles, Mumps, Rubella) 2 doses meets requirement


Dose #1_____/_____            Dose #2_____/_____ 

                M          Y                                 M     Y


Tetanus-Diphtheria (Primary series with DtaP and booster with Td in the last ten years meet requirement.)

    1. Primary series of 4 doses with DtaP or DTP


Dose #1_____/_____   Dose #2_____/_____  Dose #3_____/_____  Dose #4_____/_____

                 M       Y           M        Y                         M      Y           M        Y


    1. Tetanus-Diphtheria (Td) booster within the last ten years……………….._____/_____

                                                                                                                                                     M        Y

Polio (primary series in childhood meets requirement);  3 primary series schedules are acceptable.


1.  OPV alone (oral sabin 3 doses):……….#1 _____/_____     #2 _____/_____    #3_____/_____ 

                                                                                     M       Y                 M       Y                M        Y   


2.  IPV/OPV(sequential):……IPV #1 _____/_____    IPV#2 _____/_____    OPV #3 _____/_____  OPV #4 _____/_____

                                                               M        Y                      M         Y                        M        Y                      M        Y


3.  IPV alone (injected Salk 4 doses):  ….. #1 _____/_____   #2 _____/_____  #3 _____/_____  #4 _____/_____ 

                                                                                     M       Y               M       Y                M       Y              M       Y

Varicella (Either a history of chicken pox, a positive Varicella antibody, or two doses of vaccine meets recommendation.)


1.  History of Disease:     Yes_____     No_____ 


2.  Varicella antibody      _____/_____     Reactive_____     Non-reactive_____   

                                                M       Y


3.  Immunization     #1_____/_____     #2_____/_____  

                                          M       Y                 M       Y

Hepatitis B  (3 doses of vaccine or two doses of adult vaccine in adolescents 11-15 years of age, or a positive Hepatitis B surface antibody meets recommendation.)


      1.  Immunization:     #1_____/_____     #2 _____/_____      #3 _____/_____  

                                                    M       Y                 M       Y                   M       Y

      2.  Hepatitis B surface antibody:   _____/_____     Result:  Reactive _____  Non-reactive _____ 

                                                                            M        Y

Hepatitis A  (2 doses of Hepatitis A vaccine or 3 doses of combined Hepatitis A & B meets recommendation.)

      1.  Immunization:  #1 _____/_____     #2 _____/_____ 

                                            M       Y                  M         Y


      2.  Immunization (combined Hepatitis A & B Vaccine):  #1 _____/_____   #2 _____/_____  #3 _____/_____ 

                                                                                                                   M       Y                 M       Y               M      Y


Pneumococcal Polysaccharide Vaccine (one dose for members of high-risk groups recommended)

  1. Immunization:  #1 _____/_____

       M       Y  


Influenza (Annual immunization recommended)


_____/_____   _____/_____   _____/_____   _____/_____   _____/_____   _____/_____   _____/_____   _____/_____

   M       Y           M       Y           M       Y           M       Y          M       Y          M       Y          M       Y          M       Y 


Meningococcal  (First dose preferably at entry into college for freshmen living in dormitories or residence halls who wish to reduce their risk of meningococcal disease.)   Any student who wishes to reduce their risk of disease this vaccine is recommended.  Repeat every 3-5 years.    Meningococcal Vaccine may be purchased at:

Saline County Health Office

1825 Atchinson Ave.

Marshall, MO 65340     (660) 886-3434


1.  Immunization:  _____/_____   _____/_____

                                  M       Y          M       Y   

NOTE:  For any student living on campus who does not wish to receive this vaccination, the waiver below must be signed by the student or legal guardian if student is under the age of 18 stating you understand the risks of meningitis disease which can include: hearing loss, learning disability, brain damage, & death.




Tuberculosis Screening

1.  Does the student have signs or symptoms of tuberculosis disease?   Yes_____  No_____

If no, proceed to 2.  If Yes, proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray and sputum evaluation as indicated.


2.  Is the student a member of a high-risk group (populations in which TB is endemic) or is the student entering the health profession?  Yes_____   No_____

If No, stop.  If Yes, place tuberculin skin test. (A history of BCG vaccination should not preclude testing of a member of a high-risk group.)


3.  Tuberculin Skin Test:  Date Given_____/_____     Date Read_____/_____

Result:__________ (Record in mm of induration, if no induration, write “0”)

Interpretation (based on mm of induration as well as risk factors):  Positive_____   Negative_____ 


4.  Chest x-ray (required if tuberculin skin test is positive)  Date of x-ray_____/_____  Result Normal_____ Abnormal_____


The American College Health Association has published guidelines on tuberculosis screening of college and university students.  These guidelines are based on recommendations from the Centers For Disease Control and the American Thoracic Society.  For more information, visit   The purpose of screening for tuberculosis (TB) is to identify individuals with TB disease (active TB) or latent TB infections (LTBI) manifested by a positive tuberculin skin test.  Both TB disease and LTBI must be treated.


Health Care Provider signature___________________________________________


Address___________________________________________  Phone_____________________