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The form records student details and includes a health professional section where specific disease immunity criteria are checked, including MMR serology or vaccine dates, Hepatitis B serology or vaccine dose timing, Tdap requirements with Td follow-up when applicable, and varicella history or serology or VZV vaccine dose dates. 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Submission of documentation and whether the College provides submitted documents are also addressed in the acknowledgement section.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What evidence is required for MMR immunity?",{"text":117,"@type":113},"MMR immunity can be documented using positive serology lab results for measles, mumps, and rubella, or by recording dates of 2 MMR vaccine doses.",{"name":119,"@type":110,"acceptedAnswer":120},"How can Hepatitis B immunity be documented on the form?",{"text":121,"@type":113},"Hepatitis B immunity can be shown by positive serology with lab results, or by entering the dates for three Hepatitis B vaccine doses with the specified minimum intervals, or by entering dates for two HEPLISAV-B vaccine doses one month apart.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},429694,1791032792,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81,"preview_page_count":4},2336464648322,"https://ap-avatar.wpscdn.com/avatar/2200025388227c56fec?_k=1778556882303663488","College of Nursing  \n3800 Victory Parkway Cincinnati, OH 45207-7351 513 745-3814  \nSTUDENT IMMUNIZATION RECORD  \nI understand that my immunization record and other documentation is required in order to attend clinical courses, that it may be required fora future clinical experience/employer and that the College of Nursing is not responsible for providing submitted documentation to me. I will keep a record of my immunizations.  \nStudentsignature  Student name  DOB    \n\n| HEALTH PROFESSIONAL: COMPLETE THIS SECTION\u003Cbr>Please √ the appropriate box to signify that the requirement has been met. Provide additional documentation/explanation if appropriate. Documentation of additional vaccination will be required for negative serology results. |  |\n| --- | --- |\n| Disease | HCW Requirements for Immunity |\n| MMR\u003Cbr>(Measles, Mumps, Rubella) | □ Measles Positive serology – Date   (lab results required)\u003Cbr>□ Mumps Positive serology – Date  \u003Cbr>□ Rubella Positive serology – Date   OR\u003Cbr>□ 2 MMR vaccines-Dates 1   2   |\n| Hepatitis B | □ Positive serology – Date  (lab results required) OR\u003Cbr>□ Three doses of Hepatitis B vaccine; the first 2 doses given at least one month apart, and 3rd given at least 4 months after the 2nd Dates of Hepatitis B Vaccine:\u003Cbr>1.   2   3   OR\u003Cbr>□ Two doses of HEPLISAV-B vaccine – 1 month apart: 1   2   |\n| Tetanus, Diphtheria, Pertussis | □ 1 dose of Tdap (Adacel) (NOTE: Neither Td nor DTaP meet this requirement) .\u003Cbr>Date of Tdap Vaccine: 1.   If Tdap is older than 10 years, also provide date\u003Cbr>of subsequent Td Vaccine:   |\n| Varicella\u003Cbr>(Chicken pox) | □ History of varicella (Chickenpox) or zoster (Shingles) Date or year:   OR\u003Cbr>□ Positive serology – Date  (lab results required) OR\u003Cbr>□ 2 doses of VZV vaccine, 4-8 weeks apart.\u003Cbr>Prior recipients of 1 dose of vaccine must receive a 2nd vaccine dose.\u003Cbr>Dates of Chicken pox Vaccine: 1.   2   |\n| Signature (physician/nurse practitioner verifying information) Printed name Date signed\u003Cbr>NAME/ADDRESS/PHONE OF HEALTH CARE PROVIDER\u003Cbr> |  |\n\nNOTE TO STUDENT: A copy of an electronic immunization record from your healthcare provider will satisfy this requirement if the document includes all necessary information.","cbCaidBTulV4Nipp","https://ap.wps.com/l/cbCaidBTulV4Nipp","pdf",74836,"English","# Student Information\n## Immunization Acknowledgement and Student Details\n# Health Professional Requirements\n## MMR (Measles, Mumps, Rubella)\n## Hepatitis B\n## Tetanus, Diphtheria, Pertussis\n## Varicella (Chicken Pox)\n# Provider Verification","[{\"question\":\"What is the purpose of the Student Immunization Record form?\",\"answer\":\"It documents a student’s immunization and related records required for attendance in clinical courses and may be required for future clinical experience or employers. Submission of documentation and whether the College provides submitted documents are also addressed in the acknowledgement section.\"},{\"question\":\"What evidence is required for MMR immunity?\",\"answer\":\"MMR immunity can be documented using positive serology lab results for measles, mumps, and rubella, or by recording dates of 2 MMR vaccine doses.\"},{\"question\":\"How can Hepatitis B immunity be documented on the form?\",\"answer\":\"Hepatitis B immunity can be shown by positive serology with lab results, or by entering the dates for three Hepatitis B vaccine doses with the specified minimum intervals, or by entering dates for two HEPLISAV-B vaccine doses one month apart.\"}]","Student Immunization Record - Healthcare Requirements | PDF",1790650884]