Immunization Requirements for Nutrition
Program At Texas Woman’s University
Revised Summer 2018
Immunization Compliance Inquiries to:
Immunization Program Phone: (940) 898-3825
P.O. Box 425467 (888) 898-8825
Denton, TX 76204-5467
https://patient-twu.medicatconnect.com/
Name: Student ID:
Date of Birth: / / Phone #: ( )
Email Address: @ Alt. Phone #: ( )
Current Address:
Address City/State Zip
Sex (Male/Female): _______________________
IMPORTANT: SUBMISSION OF REQUIRED IMMUNIZATION RECORDS IS NECESSARY TO COMPLY WITH
TEXAS ADMINISTRATIVE CODE TITLE 25, P1, CH97, SUBCH B, RULE §97.61 AND THE POLICY OF TEXAS
WOMAN’S UNIVERSITY.
PROOF OF THE FOLLOWING IMMUNIZATIONS IS REQUIRED PRIOR TO CLINICALS
**
All Vaccine/Immunization records must include full dates i.e. month/day/year & health care providers’ signatures. Health care provider
initials may be considered sufficient if the document is on a health care provider’s letterhead including the name & address of the practice.
School records will NOT be accepted. Immunization records submitted without thorough documentation will not be accepted at any clinical
site and students will be required to repeat vaccines or obtain titers in lieu of vaccines if applicable. All immunization records should be
uploaded to TWU Student Health Patient Portal at https://patient-twu.medicatconnect.com/
Tdap – Tetanus, Diphtheria and Pertussis must be renewed every 10 years.
Flumust be current Flu season (September April) due annually. Record must include: Manufacturer, Flu
Lot number, expiration date, injection site and provider’s signature. Receipts are NOT accepted.
TB Screening – within past one year. If you are eligible for TB Skin testing, results MUST include induration,
even if the negative result is ‘0 mm of induration. After a positive TB Skin test, you must have a TB Blood
test prior to having a Chest X-ray.
MMR 2 doses OR Positive Titer Measles, Mumps & Rubella Titer (must submit lab report).
Varicella 2 doses OR Positive Titer – must submit lab report for Titers. History of disease accepted for
Kinesiology students only.
Hepatitis B Series (3 doses) - dose 2 (30) days after dose 1, dose 3 (5 months) after dose 2 or Positive
Hepatitis B Titer (Hepatitis B Surface Antibody) – 30 days or more after completion of Hepatitis B Series
Hepatitis A Series (2 doses 6 months apart) Denton Nutrition and Food Science Majors only.
** Please note negative titer results may require a repeat of vaccine doses and additional titer
screening.
Student must sign for immunization compliance:
I certify that, to the best of my knowledge, the above information and attached copies are true and correct.
I also give my consent for the release of my immunization records to faculty/staff at Texas Woman’s University. I further consent
to the release of my immunization records to any clinical facility that I request they be sent to for clinical rotations
or employment.
Student Signature Date Signed
In accordance with Leg. House Bill 1922, an individual is entitled to request to be informed about the information collected about them; receive and review their
information; and correct any incorrect information. Disclosure of your social security number is required in order to set up your immunization status at Texas Wo
man’s
University. Your social security number will be used as a unique number to identify you. Any further disclosure of your social security number will be governed by
the Public Information Act (Chp 552 of the Texas Government Code).
Have you ever had a positive TB Blood Test?
Algeria
TexasWoman'sUniversity Student Health Services
Tuberculosis (TB) Screening Requirement Form forHealth Profession Students
Is your country of birth listed below? Yes
No
If yes, which of these is your birth country?
In
the lists below, please check the boxes to the left of ALL countries you have resided in and/or traveled to for ≥ 8 weeks.
Afghanistan
Colombia
Iraq
Nauru
South Africa
Comoros
Kazakhstan
Nepal
South Sudan
Angola
Congo
Kenya
New Caledonia
Sri Lanka
Anguilla
Côte d'Ivoire
Kiribati
Nicaragua
Sudan
Argentina
Dem. People's Rep. of Korea
Kuwait
Niger
Suriname
Armenia
Dem. Rep. of the Congo
Kyrgyzstan
Nigeria
Swaziland
Azerbaijan
Djibouti
Lao People's Dem. Rep.
Northern Mariana Islands
Syrian Arab Republic
Bangladesh
Dominican Republic
Latvia
Pakistan
Tajikistan
Belarus
Ecuador
Lesotho
Palau
Tanzania (United Rep. of)
Belize
El Salvador
Liberia
Panama
Taiwan
Benin
Equatorial Guinea
Libya
Papua New Guinea
Thailand
Bhutan
Eritrea
Lithuania
Paraguay
Timor-Leste
Bolivia (Plurinational State of)
Ethiopia
Madagascar
Peru
Togo
Bosnia and Herzegovina
Fiji
Malawi
Philippines
Tunisia
Botswana
Gabon
Malaysia
Portugal
Turkmenistan
Brazil
Gambia
Maldives
Qatar
Tuvalu
Brunei Darussalam
Georgia
Mali
Republic of Korea
Uganda
Bulgaria
Ghana
Marshall Islands
Republic of Moldova
Ukraine
Burkina Faso
Greenland
Mauritania
Romania
Uruguay
Burundi
Guam
Mauritius
Russian Federation
Uzbekistan
Cabo Verde
Guatemala
Mexico
Rwanda
Vanuatu
Cambodia
Guinea
Micronesia (Fed. States of)
Sao Tome and Principe
Venezuela (Bolivarian Rep. of)
Cameroon
Guinea-Bissau
Mongolia
Senegal
Viet Nam
Central African Republic
Guyana
Montenegro
Serbia
Yemen
Chad
Haiti
Morocco
Sierra Leone
Zambia
China
Honduras
Mozambique
Singapore
Zimbabwe
China, Hong K
ong SAR
India
Myanmar
Solomon Islands
China, Macao SAR
Indonesia
Namibia
Somali
a
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2015. Countries with incidence rates of ≥ 20 cases per 100,000 population. For future updates, refer to http://
www.who.int/tb/country/en/.
SECTION 1
Yes No
Yes No
Yes
No
Yes No
Yes No
Did you select any of the countries above?
Have you ever had a BCG vaccine (Bacillis Calmette-Guerin)?
Have you ever had a positive TB SKIN Test (PPD) and did NOT take antibiotics for it?
Have you EVER had a TB BLOOD Test (IGRA, QuantiFERON, T-Spot)?
Do you have cancer, HIV/AIDS, kidney disease or any immunosuppressive condition?
Do you take immunosuppressive medication such as steroids, biologics or chemotherapy?
Have you ever had an atypical mycobacteria infection?
Yes No
Any YES answer requires TB BLOOD Test with T-Spot or QuantiFERON Gold; TB Skin Test is NOT accepted.
SECTION 2
Yes No
Have you ever taken antibiotics for tuberculosis?
Yes No
A YES answer in Section 2 requires you to have a Chest X-Ray and Tuberculosis Clearance Statement the first time TB documentation is submitted. Subsequent
screening requires only Tuberculosis Clearance Statement if there are no symptoms of active TB.
TWU Student ID #
Student Name Date of Birth
Student Signature
Date
This form and TB result record must be uploaded to TWU Patient Portal https://patient-twu.medicatconnect.com/default.aspx. For questions or help completing this
form, please contact TWU Student Health Services Immunization Compliance at (940) 898-3825, message using the TWU Patient Portal, or email
Immunization@twu.edu.
Yes No
Select country of birth
2
TWU Student Tuberculosis Screening and Case Management Policy Requirements
New International Students and those considered to be international by TAC §21.25(c) (formerly, HB 1403)
or TEC 54.052 due to birth or residence outside of the U.S.
Must complete the TB screening process prior to the first day of class.
Must submit the TWU Tuberculosis (TB) Screening Requirement Form for New Students
o Individuals who answer YES to any risk factor for TB are required to have a TB Blood Test
o Individuals born, resided in, or traveled to countries at low risk for TB who also answer NO
to all risk factor questions submit only the completed Form (TB Blood Test not required)
Tuberculin Skin Testing is NOT accepted for screening for these students
Tuberculosis Testing Procedure for those answering YES to any question on the Screening Form
TB Blood Testing using T-Spot or QuantiFERON Gold required
o Testing must be done in the United States within 365 days prior to the first day of classes
upon entrance into TWU
o Acceptable sites for TB screening include TWU Student Health Services, TWU
subcontracted health clinics in Dallas and Houston, US licensed private physicians, and US
licensed medical clinics
o Students who have previously taken antibiotics for TB do not need a TB Blood Test, see
below for alternate requirements
Students with negative TB Blood Test results submit test results with Form; no additional testing
required
All students with positive TB blood test results must submit BOTH of the following:
o Chest x-ray results from x-ray obtained in the U.S. within 365 days prior to the first day of
classes upon entrance to TWU
o Completed Tuberculosis Clearance Statement signed by a U.S. licensed medical professional
Students treated with antibiotics for TB infection (active or latent) in the past must submit ALL of
the following:
o Chest x-ray results from x-ray obtained in the U.S. within 365 days prior to the first day of
classes upon entrance to TWU
o Proof of antibiotic treatment, including duration of therapy
o Completed Tuberculosis Clearance Statement signed by a U.S. licensed medical professional
o New TB blood testing is not required
Chest x-ray submission requires the following to meet compliance requirements
o Positive TB Blood Test results AND/OR proof of antibiotic treatment for TB with duration
of therapy
o Completed Tuberculosis Clearance Statement signed by U.S. licensed medical professional
o Chest x-ray and Statement without test results or proof of antibiotics is NOT accepted
Non-compliance with this policy will prevent students from registering for classes.
For additional information, please refer to the TWU Student Tuberculosis Screening and Case Management
Policy https://servicecenter.twu.edu/TDClient/KB/ArticleDet?ID=34896
For questions, please call TWU Student Health Services at 940.898.3825 or visit TWU SHS website
https://www.twu.edu/student-health-services/tuberculosis-screening/