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STUDENT ID: STUDENT DOB:

STUDENT NAME:

USC IMMUNIZATIONS CHECKLIST

NOTE: You have the option to submit your vaccine records OR have your provider complete this Immunizations Checklist. If your physician’s office completes, signs and stamps this document, you must: 1) Upload this checklist including lab reports when applicable AND 2) Fill out applicable immunization date fields on MySHR. Your documentation will not be reviewed unless the date fields were filled out.

The deadline to complete all immunization requirements for the semester is September 13, 2019. Failure to complete this requirement by the deadline will result in a late fee and registration hold.

REQUIRED IMMUNIZATIONS

MMR VACCINE • Measles, Mumps & Rubella • 2 dose series OR titer

**Students born prior to 1/1/1957 are considered immune and are exempt** • Dose #1 must be on or after your 1st birthday • Dose #1 & #2 must be at least 28 days apart •

Dose #1 Date:_______________(MM/DD/YR) Dose #2 Date:_______________(MM/DD/YR) If you had the disease (measles or mumps) as a child or if you are unable to obtain proof of vaccination, you must obtain a blood titer test o If you have a negative or indeterminate titer, obtain 2 doses of MMR vaccine separated by at least 28 days POSITIVE Measles Titer Titer Date:______________(MM/DD/YR) POSITIVE Mumps Titer Titer Date:______________(MM/DD/YR) **UPLOAD A COPY OF YOUR LAB REPORT**

Value: ___________ Value: ___________

VARICELLA VACCINE • Chickenpox • 2 dose series OR titer

**Students born prior to 1/1/1980 are considered immune and are exempt** • Dose #1 must be on or after your 1st birthday • Dose #1 & #2 must be at least 28 days apart

MENINGOCOCCAL VACCINE (ACWY) • Menactra OR Menveo

**For students 21 years old and under** The most recent dose must be on or after your 16th birthday

Dose #1 Date:_______________(MM/DD/YR) Dose #2 Date:_______________(MM/DD/YR) If you had the disease (varicella/chicken pox) as a child or if you are unable to obtain proof of vaccination, you must obtain a blood titer test o If you have a negative or indeterminate titer, obtain 2 doses of Varicella vaccine separated by at least 28 days o POSITIVE Varicella Titer Titer Date:______________(MM/DD/YR) Value: ___________ **UPLOAD A COPY OF YOUR LAB REPORT**

Dose #1 Date:_____________(MM/DD/YR) Dose #2 Date:_____________(MM/DD/YR)


REQUIRED FOR INTERNATIONAL STUDENTS ONLY TUBERCULOSIS SCREENING (BLOOD TEST) • Tspot or Quantiferon Gold

STRONGLY RECOMMENDED IMMUNIZATIONS

TDAP VACCINE • Tetanus/Diphtheria WITH Pertussis (Whooping Cough) HEPATITIS A VACCINE • 2 dose series HEPATITIS B VACCINE • 3 dose series

HPV VACCINE (GARDASIL 9) • Human Papilloma Virus Vaccine • 3 dose series MENINGOCOCCAL B VACCINE • Trumenba or Bexsero • 2 or 3 dose series

POLIO VACCINE • 4 dose childhood series

INFLUENZA VACCINE

Submit a Tspot or Quantiferon Gold lab test result that was taken within 6 months of your first semester (must be completed at lab in the United States) Tspot Test Date:______________(MM/DD/YR) Quantiferon [__] Positive [__] Negative [__] Borderline 1 dose within the last 10 years •

Dose Date:_______________(MM/DD/YR)

• •

Dose #1 Date:_______________(MM/DD/YR) Dose #2 Date:_______________(MM/DD/YR)

• • •

Dose #1 Date:_______________(MM/DD/YR) Dose #2 Date:_______________(MM/DD/YR) Dose #3 Date:_______________(MM/DD/YR)

Recommended for all students (all genders) up to the age of 26 years old • Dose #1 Date:_______________(MM/DD/YR) • Dose #2 Date:_______________(MM/DD/YR) • Dose #3 Date:_______________(MM/DD/YR) Recommended for ages 16-23 years old • Dose #1 Date:_______________(MM/DD/YR) • Dose #2 Date:_______________(MM/DD/YR) • Dose #3 Date:_______________(MM/DD/YR) • • • •

Dose #1 Date:_______________(MM/DD/YR) Dose #2 Date:_______________(MM/DD/YR) Dose #3 Date:_______________(MM/DD/YR) Dose #4 Date:_______________(MM/DD/YR)

Date:_______________(MM/DD/YR)

I ATTEST THAT ALL DATES, IMMUNIZATIONS AND LAB RESULTS LISTED ARE CORRECT AND ACCURATE Provider’s Name:___________________________________(MD/NP/PA/RN) Provider’s Signature:______________________________ Date:_______________

Medical Practice Stamp (required)

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Immunization Checklist 2019-2020  

Immunization Checklist 2019-2020  

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