Date: -------------------------------

TO WHOM IT MAY CONCERN

Fatima College of Health Sciences certifies that the student named below is enrolled in the current Semester of
the academic year 2021-2022 and she is expected to Start clinical internship on upcoming Semester.
We request your cooperation with the following required tests and vaccination.
STUDENT DETAILS

NAME: -------------------------------------------------- STUDENT ID NO: --------------------------------

TESTS:
 P.P.D. Test / QuantiFERON TB test -----------------------------------------------
 Hepatitis B Antibody Titer -----------------------------------------------
 Hepatitis C Antibody -----------------------------------------------
 Varicella Antibody titer -----------------------------------------------
 D/T or Tdap -----------------------------------------------
 MMR ----------------------------------------------
 HIV ----------------------------------------------
 Influenza ----------------------------------------------
 COVID – 19 ----------------------------------------------
• Disregard if DT vaccines was received within (10) ten years.
• Disregard if evidence of 2 doses of vaccination against MMR is available.

□ NURSE NAME: ------------------------------------------------

□ SIGNATURE: ---------------------------------------------------
Please stamp this document from the clinic

FCHS STAFF:

Note: All students are required to present their Childhood and Secondary vaccination chart to the Registered School Nurse clinic. If there
are any inquiries, please do not hesitate to call to School Nurse in your campus.

□ SCHOOL NURSE NAME: -------------------------------------

□ SIGNATURE: ----------------------------------------------------

Fatima College of Health Sciences