Vaccinations Documents

A Health Care Provider Must Complete the Following All Test Results Must Be Attached With This Form

I. Tuberculin Skin Test
(Must be less than one year old. All tuberculin skin tests must be valid through the entire clinical clerkship)

For those with a history of a positive tuberculin test, the following is mandatory:

Chest XVray report: oPositive oNegative

II. Immunization Record
(Students must prove immunity to ALL of the following prior to commencement of clinical clerkships)
HBsAb titer result: Positive/Immune/Past Exposure, Negative/Non-Immune

Hepatities B Vaccine 1st

Measles Vaccine date

Rubella Vaccine date

Varicella Vaccine date

Influenza Vaccine date

Date of last Physical exam

I verify that the above information is true

Fax

Signature of Physician

General health
List any recent or continuing health concerns

List any physical or learning disabilities

If yes, Physician's Name

Drug or Food Allergies

Medical History
Please check if you have ever had any of the following

Certification
I certify that all responses made on this form are complete, true and accurate. I understand that if there are any changes in my health status, I will contact AICG immediately. I understand that if I misrepresented or failed to provide the information requested on this form, then I may be terminated from participation in or dismissed from my clinical clerkships.
Student signature

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