IMMUNIZATION RECORD. City State Zip Student Cell Phone Number. Exemptions from Immunization Requirements

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1 FORM DUE DATE Fall Semester June 1st Spring Semester December 1st IMMUNIZATION RECORD All students must cmplete this frm and return t Health Services by date due. Frms can be submitted via (scanned t lrd-stutt@centenaryuniversity.edu), fax t , mail t Wellness Center fr Cunseling and Health, 605 Grand Avenue, Hackettstwn, NJ 07840, r drp ff at Wellness Center (605 Grand Ave). Exemptin letters and cpies f immunizatin recrds frm High Schl/Cllege/Public Health Department r Health Care Prvider must be attached, r this frm requires signature f yur Health Care Prvider. PLEASE COMPLETE THIS FORM IN ITS ENTIRETY! Last Name Maiden First Middle Initial Scial Security Number Address Hme Phne Number City State Zip Student Cell Phne Number DATE f BIRTH Entrance Date Gender M F T Student Status (circle all that apply): Undergrad Graduate RESIDENT Full-time Part-time Main campus SPS Matriculated Nn-matriculated I have previus recrds at Centenary Cllege YES NO Dates Attended COMMUTER Exemptins frm Immunizatin Requirements Students enrlled in strictly nline prgrams are exempted frm immunizatin requirements. Any student may seek exemptin frm immunizatin requirements fr medical r religius reasns. A student seeking exemptin frm required immunizatins fr a medical reasn, must submit a written statement frm their healthcare prvider which indicates that the immunizatin is medically cntraindicated as enumerated by the Advisry Cmmittee n Immunizatin Practices (ACIP). The statement must specify the perid f time the student is exempt. When the student s medical cnditin permits immunizatin, the medical exemptin shall thereupn terminate. Medical exemptins must be updated annually by the student and their health care prvider, and must be re-submitted t the health ffice. A student seeking exemptin frm required immunizatins fr a religius reasn, must submit a written statement signed by the student (r parent/legal guardian if the student is a minr) explaining hw the administratin f a vaccine cnflicts with the student s religius beliefs. This written statement will be kept as part f the student s health recrds. Students brn BEFORE 1957 are exempt frm measles, mumps and rubella vaccine requirements. Students brn BEFORE 1980 are exempt frm chickenpx vaccine requirements. *In the event f a cntagius utbreak, any student wh has been exempted frm immunizatins may nt be allwed n campus.* Students claiming exemptins shuld check what applies belw and attach supprting dcumentatin. EXEMPTIONS: AGE MEDICAL RELIGIOUS MMR HEPATITIS B MENINGOCOCCAL VARICELLA

2 THE FOLLOWING IMMUNIZATIONS ARE REQUIRED OF ALL STUDENTS UNLESS OTHERWISE EXEMPTED. PLEASE COMPLETE WITH DATES OF VACCINATION and/ r TITER RESULTS. 1. MMR (MEASLES, MUMPS, RUBELLA)-All students brn after 1956 are required t have tw dses; the first dse given at age 12 mnths r later, and the secnd dse given at least 28 days after the first dse. If vaccine dates are unknwn, a bld test called an MMR titer can be dne. MMR #1 (M/D/Y) MMR #2 (M/D/Y) OR Measles (2 dses required) #1 (M/D/Y) #2 (M/D/Y) Mumps (1 dse required) (M/D/Y) Rubella (1 dse required) (M/D/Y) OR MMR TITER Date Result Measles Titer Mumps Titer Rubella Titer 2. HEPATITIS B-All students are required t have three dses f vaccine, r tw dses f adult vaccine in adlescents years f age, r a psitive hepatitis B surface antibdy. HEP B #1 (M/D/Y) HEP B #2 (M/D/Y) HEP B #3 (M/D/Y) Adult Frmulatin Child Frmulatin Adult Frmulatin Child Frmulatin Adult Frmulatin Child Frmulatin OR Date Result Hep BsAB Titer 3. TETANUS, DIPHTHERIA, PERTUSSIS-All students are required t have had a Tetanus Bster within 10 years f admissin date. Tdap bster is recmmended fr ages unless cntraindicated. Td (M/D/Y) TdaP (M/D/Y) 4. VARICELLA (CHICKENPOX)-All students brn after 1980 are required t shw histry f chickenpx disease OR Dcumentatin f Varicella Immunity Titer OR 2 varicella vaccines Date f Chickenpx Disease OR Varicella IgG Titer OR Varicella Vaccine #1 AND Varicella Vaccine #2 5. MENINGOCOCCAL-All students residing in Campus Husing, are required t have a meningitis vaccine within 5 years f admissin date. Quadrivalent cnjugate is preferred. Vaccine #1 Vaccine #2 6. TUBERCULOSIS(TB) SCREENING TESTING-All students at risk fr Tuberculsis are required t have TB testing (SEE ATTACHED) RECOMMENDED BUT NOT REQUIRED VACCINES Hepatitis A #1 (M/D/Y) Hepatitis A #2 (M/D/Y) Influenza Vaccine (M/D/Y) HPV Vaccine #1(M/D/Y) HPV #2(M/D/Y) HPV #3 (M/D/Y) SIGNATURE OF HEALTHCARE PROVIDER DATE

3 TUBERCULOSIS (TB) SCREENING/TESTING Please answer the fllwing questins: Have yu ever had clse cntact with persns knwn r suspected t have active TB disease? Were yu brn in ne f the cuntries listed belw that have a high incidence f active TB disease? (If yes, please CIRCLE the cuntry, belw) Afghanistan Cte d Ivire Kenya Nicaragua Suth Africa Algeria Demcratic Peple s Kiribati Niger Suth Sudan Angla Republic f Krea Kuwait Nigeria Sri Lanka Argentina Demcratic Republic f Kyrgyzstan Niue Sudan Armenia the Cng La Peple s Demcratic Pakistan Suriname Azerbaijan Djibuti Republic Palau Swaziland Bahrain Dminican Republic Latvia Panama Tajikistan Bangladesh Ecuadr Lesth Papua New Guinea Thailand Belarus El Salvadr Liberia Paraguay Timr-Leste Belize Equatrial Guinea Libya Peru Tg Benin Eritrea Lithuania Philippines Trinidad and Tbag Bhutan Estnia Madagascar Pland Tunisia Blivia (Plurinatinal State Ethipia Malawi Prtugal Turkey f) Bsnia and Herzegvina Fiji Malaysia Qatar Turkmenistan Btswana Gabn Maldives Republic f Krea Tuvalu Brazil Gambia Mali Republic f Mldva Uganda Brunei Darussalam Gergia Marshall Islands Rmania Ukraine Bulgaria Ghana Mauritania Russian Federatin United Republic f Burkina Fas Guatemala Mauritius Rwanda Tanzania Burundi Guinea Mexic Saint Vincent and the Uruguay Cab Verde Guinea-Bissau Micrnesia (Federated Grenadines Uzbekistan Cambdia Guyana States f) Sa Tme and Principe Vanuatu Camern Haiti Mnglia Senegal Venezuela (Blivarian Central African Republic Hnduras Mrcc Serbia Republic f) Chad India Mzambique Seychelles Viet Nam China Indnesia Myanmar Sierra Lene Yemen Clmbia Iran (Islamic Republic f) Namibia Singapre Zambia Cmrs Iraq Nauru Slman Islands Zimbabwe Cng Kazakhstan Nepal Smalia Surce: Wrld Health Organizatin Glbal Health Observatry, Tuberculsis Incidence Cuntries with incidence rates > 20 cases per 100,000 ppulatin. Fr future updates, refer t Have yu had frequent r prlnged visits* t ne r mre f the cuntries listed abve with a high prevalence f TB disease? (If yes, CHECK the cuntries, abve) Have yu been a resident and/r emplyee f high-risk cngregate settings (e.g., crrectinal facilities, lng-term care facilities, and hmeless shelters)? Have yu been a vlunteer r health-care wrker wh served clients wh are at increased risk fr active TB disease? Have yu ever been a member f any f the fllwing grups that may have an increased incidence f latent M. tuberculsis Infectin r active TB disease medically underserved, lw-incme, r abusing drugs r alchl? If the answer t all f the abve questins is NO, n further testing r further actin is required. If the answer is YES t any f the abve questins, Centenary Cllege requires that yu receive TB testing as sn as pssible but at least prir t the start f the subsequent semester). The significance f the travel expsure shuld be discussed with a health care prvider and evaluated.

4 TUBERCULOSIS (TB) RISK ASSESSMENT (t be cmpleted by health care prvider) Clinicians shuld review and verify the infrmatin abve. Persns answering YES t any f the questins in Tuberculsis (TB) Screening/Testing are candidates fr either Mantux tuberculin skin test (TST) r Interfern Gamma Release Assay (IGRA), unless a previus psitive test has been dcumented. Histry f a psitive TB skin test r IGRA bld test: (If yes, dcument belw) Yes N Histry f BCG vaccinatin? (If yes, cnsider IGRA if pssible.) Yes N 1. TB Symptm Check Des the student have signs r symptms f active pulmnary tuberculsis disease? Yes N If N, prceed t 2 r 3 If Yes, check belw: Cugh (especially if lasting fr 3 weeks r lnger) with r withut sputum prductin Cughing up bld (hemptysis) Chest pain Lss f appetite Unexplained weight lss Night sweats Fever Prceed with additinal evaluatin t exclude active tuberculsis disease including tuberculin skin testing, chest x-ray, and sputum evaluatin as indicated. 2. Tuberculin Skin Test (TST) (TST result shuld be recrded as actual millimeters (mm) f induratin, transverse diameter; if n induratin, write 0. The TST interpretatin shuld be based n mm f induratin as well as risk factrs.)** Date Given: / / Date Read: / / M D Y M D Y Result: mm f induratin ** Interpretatin: psitive negative Date Given: / / Date Read: / / M D Y M D Y Result: mm f induratin ** Interpretatin: psitive negative ** Interpretatin guidelines >5 mm is psitive: Recent clse cntacts f an individual with infectius TB persns with fibrtic changes n a prir chest x-ray, cnsistent with past TB disease rgan transplant recipients and ther immunsuppressed persns (including receiving equivalent f >15 mg/d f prednisne fr > 1 mnth.) HIV-infected persns >10 mm is psitive: recent arrivals t the U.S. (< 5 years) frm high prevalence areas r wh resided in ne fr a significant amunt f time injectin drug users mycbacterilgy labratry persnnel residents, emplyees, r vlunteers in high-risk cngregate settings

5 persns with medical cnditins that increase the risk f prgressin t TB disease including silicsis, diabetes mellitus, chrnic renal failure, certain types f cancer (leukemias and lymphmas, cancers f the head, neck, r lung), gastrectmy r jejunileal bypass and weight lss f at least 10% belw ideal bdy weight. >15 mm is psitive: persns with n knwn risk factrs fr TB wh, except fr certain testing prgrams required by law r regulatin, wuld therwise nt be tested. The significance f the travel expsure shuld be discussed with a health care prvider and evaluated. 3. Interfern Gamma Release Assay (IGRA) Date Obtained: / / (specify methd) QFT-GIT T-Spt Other M D Y Result: negative psitive indeterminate brderline (T-Spt nly) Date Obtained: / / (specify methd) QFT-GIT T-Spt Other M D Y Result: negative psitive indeterminate brderline (T-Spt nly) 4. Chest x-ray: (Required if TST r IGRA is psitive) Date f chest x-ray: / / Result: nrmal abnrmal Management f Psitive TST r IGRA All students with a psitive TST r IGRA with n signs f active disease n chest x-ray shuld receive a recmmendatin t be treated fr latent TB with apprpriate medicatin. Hwever, students in the fllwing grups are at increased risk f prgressin frm LTBI t TB disease and shuld be priritized t begin treatment as sn as pssible. Infected with HIV Recently infected with M. tuberculsis (within the past 2 years) Histry f untreated r inadequately treated TB disease, including persns with fibrtic changes n chest radigraph cnsistent with prir TB disease Receiving immunsuppressive therapy such as tumr necrsis factr-alpha (TNF) antagnists, systemic crticsterids equivalent t/greater than 15 mg f prednisne per day, r immunsuppressive drug therapy fllwing rgan transplantatin Diagnsed with silicsis, diabetes mellitus, chrnic renal failure, leukemia, r cancer f the head, neck, r lung Have had a gastrectmy r jejunileal bypass Weigh less than 90% f their ideal bdy weight Cigarette smkers and persns wh abuse drugs and/r alchl ** Ppulatins defined lcally as having an increased incidence f disease due t M. tuberculsis, including medically underserved, lw-incme ppulatins Student agrees t receive treatment Student declines treatment at this time HEALTH CARE PROVIDER Name Signature Address Phne ( )