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Visiting Student Immunization Information

Loyola University Medical Center

Requirements must be met no later than two weeks prior to the beginning date of the elective. Any questions may be
directed to the Student Health Service at (708) 531-7900.
Student Name: Date of Birth:
School: Email Address:
Rotation: Dates of Rotation: to
Loyola University Stritch School of Medicine requires students to show proof of surveillance for tuberculosis infection
within 12 months of their scheduled clinical rotation and proof of immunization against Measles, Mumps, Rubella,
Varicella, Hepatitis B*, and Tetanus, Diphtheria & Pertussis (TDAP vaccine), including titers. Proof of annual
influenza immunization required for rotations between November 1 and April 30. A health care professional must verify
all information on this form and date and sign it in the space provided at the bottom.

Serology date
Live attenuated virus
& (attach copy of titer or Exemption
vaccine dates

Measles (Rubeola) Dose 1

Dose 2

Dose 1
Dose 2

German Measles Dose 1


TDAP (Tetanus, Dose 1

Diphtheria, (must be within
Pertussis) last 10 yrs)

Chickenpox Dose 1
Dose 2

or x-ray if indicated/ or BCG vaccine or History

TB Screen
Date attach report date
(must be within 12 mo.
of rotation dates)
mm of induration

Vaccine Series Quantitative Hep B Surface Antibody Titer*

Hepatitis B Dose 1 Date & Result (attach copy) or Exemption
Dose 2
Dose 3
*Hepatitis B antibody titer is recommended for proof of immunity. The Hepatitis B titer should be a quantitative test to surface
antibody with adequate immunity when the value is >10 MUI/ML.
Seasonal Flu If your rotation will be between the dates of November 1 and April 30, please attach a copy of the
Vaccine documentation verifying your receipt of the seasonal flu vaccine.

Signature of Health Care provider verifying above information:

Print Name: Date:
Address: Phone:

UPDATED: 10/14/10
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