Immunization Form
CERRITOS COLLEGE - HEALTH OCCUPATIONS DIVISION
DENTAL HYGIENE DEPARTMENT
IMMUNIZATION / PROOF OF IMMUNITY FORM
Student's name ______________________________________________________________________________
As a part of the physical examination or documented history, the above person has the following. Please make surethe medical doctor signs at each space where indicated.
1. TB Clearance: Skin test must be repeated every 6 months. If skin test is positive, a chest x-ray must be completed. Please attach documentation of positive skin test and negative chest x-ray. Chest x-rays must be repeated every two years.
Type of test _________________________________________________________________________
Date completed _______________________________________________________________________
Results: Positive _______________________________ Negative _______________________________
Signature of Medical Doctor _____________________________________________________________
2. Last Tetanus-diphtheria immunization (must be repeated every 10 years):
Date completed _______________________________________________________________________
Signature of Medical Doctor _____________________________________________________________
3. Immunity: PROOF OF IMMUNITYMUSTBE PROVIDED BY TITER. CLINICAL LABORATORY REPORTS WITH FACILITY STAMP & MEDICAL DOCTOR'S SIGNATURE ARE REQUIRED FOR THE FOLLOWING:
A. Hepatitis B (presence of anti-HBc or anti-HBs):
B. Rubeola
C. Mumps
D. Rubella
E. Varicella
Note: If any titer shows a negative response, appropriate immunizations are required and FOLLOW-UP TITERS MUST BE COMPLETED and submitted to the Dental Hygiene Department.
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