upenn體檢 .pdf


Nom original: upenn體檢.pdfAuteur: endyb

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Student Health Service
Immunization Compliance Office
Phone: 215 746 3535 option #4 then #5 Fax: 215 746 0909
Email: HUimmun@pobox.upenn.eduU
Part 1 of 2
Student Last Name: (Please print) ________________________________________ Student First Name: (Please print) ___________________________________________
Date of Birth: ___/___/___

Student I.D.__________________

U

U

REQUIRED IMMUNIZATIONS - TO BE COMPLETED BY HEALTH CARE PROVIDER

Please fax completed and signed/stamped form to 215 746 0909. Please include any source documentation such as blood tests, x-ray reports, etc.
Please go to http://www.vpul.upenn.edu/shs/immreq.php for more information about required immunizations.

HEPATITIS B:

Requirement: Three doses (doses one and two given at least four weeks apart and the third dose should be at least four to six months after second dose)
or a blood test showing immunity.
Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___ OR Blood Test( Check one): Positive
U

U

U

U

U

Negative

Quantitative Result___________ Date ___/___/___
U

U

OR
Twinrix
Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___
U

U

U

U

MEASLES, MUMPS, RUBELLA (MMR):
later) or a blood test showing immunity.
Dose 1- ___/___/___ Dose 2 - ___/___/___
U

U

U

U

Requirement: Two doses (dose one must be administered after the first birthday, and 2nd dose given a minimum of four weeks

OR:

U

MEASLES
MUMPS

Dose 1- ___/___/___ Dose 2- ___/___/___ OR Blood Test: Positive

Negative

Quantitative Result_________ Date ___/___/___ Infection Date___/___/___

Dose 1- ___/___/___ Dose 2- ___/___/___ OR Blood Test: Positive

Negative

Quantitative Result_________ Date ___/___/___ Infection Date___/___/___

RUBELLA

Dose 1- ___/___/___ Dose 2- ___/___/___ OR Blood Test: Positive

Negative

Quantitative Result_________ Date ___/___/___

U

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MENINGOCOCCAL VACCINE:

Requirement: 1 dose since age 16 for all incoming students living in campus housing who are age 21 or younger. Note date of most recent
vaccine. At minimum, serogroups A, C, Y, and W-135 must be covered. See optional immunization sheet (part Two) to record any meningococcal vaccine that does not meet this
requirement.
MENACTRA
Date: ___/___/___
OR:
MENVEO
Date: ___/___/___
OR:
MENOMUNE
Date: ___/___/___
(acceptable but not preferred)
None of the above:
Date: ___/___/___ Explain: ____________________________________

Incoming students living on campus who are age 22 or older may either submit proof of vaccination since age 16 or submit the
Meningococcal Vaccine Waiver.
TETANUS-DIPHTHERIA and PERTUSSIS (Tdap): Requirement: 1 dose

Tdap: Dose 1 U___/___/___U T T

VARICELLA (Chicken Pox): Requirement: Two doses of chicken pox vaccine are required at least one month apart. (Must be administered after 1995) Positive immune titer
verifying immunity is acceptable or History of disease.

Dose 1 - ___/___/___ Dose 2 - ___/___/___ OR Blood Test: Positive
U

U

U

U

Negative

Quantitative Result___________

Date ___/___/___ Infection Date ___/___/___
U

U

TUBERCULOSIS:

The University performs targeted TB testing. All students must complete the online TB Risk Screening form. If TB testing is indicated by this screening tool,
students may satisfy the TB testing requirement in one of 2 ways: 1) Submit a negative IGRA blood test for TB infection, such as Quantiferon-Gold or TSpotTB, within 12 months of
entrance to Penn or 2) make an immunization appt at Student Health Service (SHS) to have a TB skin test (PPD). Please note that SHS DOES NOT ACCEPT TB SKIN TEST (PPD)
RESULTS PLACED BY PROVIDERS OUTSIDE OF SHS. Students with documented TB history (positive test result, chest xray report, treatment, etc) can make an appointment with
a nurse for review.
IGRA (Interferon Gamma Release Assay) blood test for TB infection, if indicated (check one): positive __ negative __
other result (specify) ________________________________; Date ___/___/___

Health Care Provider Information

Organizational Stamp:

Name (Please print) ________________________________________________ Title _______________________________________
Signature _______________________________________

Date:_____________ Phone:__________________________

Address ___________________________________________________________________________________________________________

Student Health Service
Immunization Compliance Office
Phone: 215 746 3535 option #4 then #5 Fax: 215 746 0909
email: HUimmun@pobox.upenn.eduU
Part 2 of 2

Student Last Name: (Please print) ________________________________________ Student First Name: (Please print) ___________________________________________

Date of Birth: ___/___/___

Student I.D.__________________

U

OPTIONAL IMMUNIZATION HISTORY - TO BE COMPLETED BY HEALTH CARE PROVIDER
Please fax completed and signed/stamped form to 215 746 0909

BCG Note: BCG vaccine does NOT satisfy TB requirement for students in high risk groups Dose - ___/___/___
U

Tpd Dtp:U U___/___/___

Tpd/Dtp Note: Does NOT satisfy Tdap Immunization Requirement

MENINGOCOCCAL VACCINE (Other) : Dose 1 - ___/___/___ Groups A, C ?
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Groups A?

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GARDASIL (HPV) Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___

Tpd Dtp: ___/___/___

U

RABIES: Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___ OR Blood Test: (circle one) Positive / Negative Quantitative Result___________ Date - ___/___/___
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PNEUMOCOCCAL: Dose - ___/___/___
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JAPANESE ENCEPHALITIS: Dose 1 - ___/___/___

U

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POLIO (IPV/OPV): Dose 1 - ___/___/___

U

HEPATITIS A: Dose 1 - ___/___/__ Dose 2 - ___/___/___
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YELLOW FEVER: Dose 1 - ___/___/___
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OTHER:
Vaccine ______________________: Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___
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Vaccine ______________________: Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___
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Vaccine ______________________: Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___

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Vaccine ______________________: Dose 1 - ___/___/___ Dose 2 - ___/___/___ Dose 3 - ___/___/___
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Blood Test:_______________________ (circle one) Positive / Negative Result___________ Date - ___/___/___
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Blood Test:_______________________ (circle one) Positive / Negative Result___________ Date - ___/___/___
U

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Organizational Stamp:

Health Care Provider Information
Name (Please print) ________________________________________________ Title _______________________________________
Signature _______________________________________

Date:______________Phone________________________________

Address _______________________________________________________________________________________________________


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