Name: RUID: Last, First MI This section is to be completed by the students' licensed healthcare provider. VACCINE Dose #1 Date
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1 Name: RUID: Last, First MI This section is to be completed by the students' licensed healthcare provider. VACCINE Dose #1 Dose #2 Dose #3 of positive immune titer MMR (Measles, Mumps, Rubella) 2 Doses REQUIRED All doses of MMR, given singly or in combination, must be given after 1 year of age and at least one month apart. MMR requirement is only for those born in 1957 or later. MEASLES 2 Doses REQUIRED MUMPS 2 Doses REQUIRED RUBELLA (German Measles) 2 Doses REQUIRED TDAP: s of initial series and boosters ( booster must be within past ten years) Polio: s of initial series and booster (Must have had one booster) Varicella: (if had 2 doses more than one month apart - titer not required) If had disease, titer required Mantoux 2 step TB SKIN TESTING REQUIRED # 1 / / Result: negative positive mm # 2 / / Result: negative positive mm If positive TB test: Must supply chest X-ray result and treatment date, if applicable. Treatment: X-ray Booster date Booster date Normal Abnormal Treatment Required no yes HEPATITIS B (ADULT) REQUIRED 3 doses OTHER VACCINATIONS: (Consult your personal physician or Rutgers Health Services if you have questions about these immunizations.) Dose #1 Dose #2 Dose #3 *MENINGOCOCCAL MENINGITIS REQUIRED for all undergraduate, graduate, and transfer students who are new to Rutgers University AND are new to University housing. Influenza vaccine: one dose annually by December 1 (waiver available for medical contraindications) of positive immune Titer *Protects against a common cause of bacterial meningitis, a rare but potentially fatal disease with early symptoms resembling the flu. Symptoms include high fever, severe headache, stiff neck, vomiting, and a rash. As many as 15 college students die annually from the disease. It is transmitted by coughing and direct contact, not by casual classroom contact. It affects people of any age, but 1st year students living in residence halls are at increased risk of contracting the disease. Healthcare Provider Name, Address and Signature, Degree Provider Signature and Degree Return Form to: Rutgers University Camden: Student Health Office 326 Penn St - Second Floor Camden, NJ Phone
2 A copy of each of the following lab results must be attached: Rubella Rubeola Mumps Varicella - Titer only required if had infection; otherwise if received 2 immunizations at least 4 weeks apart, titer not required. Hepatitis B Surface Antibody (4-8 weeks after final immunization) *** There is no expiration on titers. Rutgers School of Nursing Physical Examination Record
3 NAME RUID Permanent Mailing Address Zip Code Primary Campus: Camden Mays Landing Blackwood Telephone # - - Gender: Male Female of Birth / / PHYSICAL EXAMINATION REPORT (Complete All Items) Height Weight Blood Pressure Pulse Vision: with correction R 20/ L 20/ Hearing Rt Lt without correction R 20/ L 20/ Appearance Nutrition Skin Head/Neck Glands Eyes Ears Nose Mouth/Teeth/ Throat Chest Lungs Heart Abdomen Back Extremities Testes Genitalia/Pelvic Neurological Normal Abnormal Description of Abnormal Findings Findings: is able to function in clinical experiences with the following restrictions: None Other Signature MD; DO; APRN Return Form to: Rutgers University Camden: Student Health Office 326 Penn St - Second Floor Camden, NJ Phone
4 Verification of Annual PPD and Influenza Immunization Administration NAME RUID Influenza vaccine TO BE COMPLETED BY HEALTH CARE PROVIDER: Vaccine Administered / / Vaccine Manufacturer: GlaxoSmithKline; Other Vaccine Lot Number Expiration : Site of Injection: Left Right DELTOID Route: IM Record any reaction observed in the first 20 minutes after vaccination administration: Provider Signature/: / / PPD Skin Test Information TO BE COMPLETED BY HEALTH CARE PROVIDER: This section MUST be completed and signed by a licensed health care provider. Please provide the information below: test administered (MM/DD/YYYY): test read (MM/DD/YYYY): Reading/Result in millimeters induration: Name of health care provider (printed): Provider Signature/: / / Provider s phone number: ( )
5 Health Insurance: In addition to the university-sponsored insurance, the student has the following insurance: PPO HMO Medicaid Medicare University-Sponsored Name of Insurance Carrier: Address of Insurance Carrier: Subscriber s Name: Policy Number: Group Number: Name of Employer: Address of Employer:
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