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T h e U niversity Health Center (University of Georgia)

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CERTIFICA
TE OF IMMUNIZATION (REQUIRED TO REGISTER FOR CLASS)
(Ok to attach GRITS or other certified immunization record)
REQUIRED IMMUNIZATIONS
REQUIREMENT (MM/DD/YYYY)
REQUIRED FOR:
MMR
(Measles,
Mu
mps, Rubella)
OR
Measles
(Rubeola)
AND
Mumps
AND
Rubella (German
M
easles)
#1
____/____/_________
#2
____/____/_________
OR
#1____/____/______ # 2 ____/____/______
OR Attached antibody titer (blood test) lab report
#1 ____/____/_______ #2 ____/____/________
OR Attached antibody titer (blood test) lab report
#1____/____/__________
OR Attached antibody titer (blood test) lab report
• All foreign-born students regardless of year born
• US/Canadian students born in 1957 or later
• 1
st
due at 12 months of age or older
• 2
nd
dose administered no earlier than 28 days after 1
st
dose
• US/Canadian students born in 1957 or later
• If antibody titer does not indicate immunity, injection
series required.
• 1
st
due at 12 months of age or older
• 2
nd
dose administered no earlier than 28 days after 1
st
dose
Varicella (Chicken
Pox)
#1 ____/____/______ #2 ____/____/______
OR
Attached antibody titer (blood test) lab report
OR
Definitive diagnosis of varicella by healthcare
provider. Provide statement from provider
verifying previous infection.
• SELF/PARENTAL REPORTED HISTORY OF DISEASE
• NOT ACCEPTED
• All foreign-born students regardless of year born.
• US/Canadian born students born during or after 1980.
• 1
st
due at 12 months of age or older
• 2
nd
dose administered no earlier than 28 days after 1
st
dose
• If antibody titer does not indicate immunity, injection
series required
Tetanus, Diphtheria,
Pertussis
(Tdap)
Tdap ____/____/_________ (REQUIRED)
If unable at home country, obtain at UGA
• One dose of Tdap for all students within past 10 years.
Hepatitis
B
#1 ____/____/__________
#2 ____/____/__________
#3 ____/____/__________
OR Attached antibody titer (blood test) lab
• All Students who will be 18 or younger on the first day of
class.
• If antibody titer does not indicate immunity, injection
series required.
• You must submit the antibody titer report on lab letterhead
from a certified lab with definitive lab values in English.
Tuberculosis (TB)
All students MUST complete the Tuberculosis
Screening Questionnaire found on
www.uhs.uga.edu/info/forms
• If the answer to any of the TB screening questions is YES, then
must complete the TB Clinical Risk Assessment Part II of Form,
including TST or IGRA by physician.
Meningococcal
Vaccine
ACWY(MCV4)
(
Strongly Recommended for all students <22)
#1 ____/____/_________
#2 ____/____/_________
Menactra or Menveo (Please circle one)
• All newly admitted UGA students living in Campus Housing,
or
• Sorority or Fraternity Houses.
• NOTE: A student may sign a statement of understanding in
lieu of providing proof of immunization.
• Review meningitis disease information at:
www.uhs.uga.edu/healthtopics/meningitis
Recommended
Vaccines:
Meningitis B Vaccine #1 ____/ ___/ _____
#2 ____/ ___/ _____ #3 ____/ ___/ _____ (Bexsero/Trumenba please circle)
Hepatitis A #1 ____/ ___/ _____
#2 ____/ ___/ _____
HPV #1 ____/ ___/ ______ #2 ____/ ___/ _____ #3 ____/ ___/ _____
Request for Religious Exemption: I affirm that the immunizations required by Request for
Permanent
Medical Contraindication
the University System of Georgia, are in conflict with my religious beliefs (Attach Verification by HealthCare Provider)
I understand I am subject to exclusion in the event of an outbreak of
disease which immunization is required. (Attach Notarized Affidavit)
REQUIRED SIGNATURE
OF
PHYSICIAN
OR
HEALTH
FACILITY:
Name Address Phone Number _
Si
g
na
t
u
r
e
Da
te
Revised: 6/17; 5/19; 2/2020
T h e U niversity Health Center
The University of Georgia
Athens, GA 30602-1755
706-542-8617
Health Information
706-542-4959 Fax
Name:
UGA
ID#: 81 _
Date
of
Birth:
/
/
Phone:
click to sign
signature
click to edit
UNIVERSITY
HEALTH CENTER
University of Georgia
Athens, GA 30602-1755
NAME:
UGA
ID#:
Phone: 706-542-1162
Fax
Nr:
706-542-4959
Date
of
Birth:
or
706-583-0777
Part
I:
Tuberculosis (TB) Screening
Questionnaire
Please answer the following questions:
1. Have you ever had close contact with persons known or suspected to have active TB disease? Yes No
2. Were you born in one of the countries listed below that have a high incidence of active TB disease?
(If YES, please CIRCLE the country, below)
Yes No
Afghanistan
Algeria
Angola
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Central African Republic
Chad
China
Colombia
Comoros
Congo
Côte d'Ivoire
Democratic People's Republic of
Korea
Democratic Republic of the
Congo
Djibouti
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Gabon
Gambia
Georgia
Ghana
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran (Islamic Republic of)
Iraq
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic
Republic
Latvia
Lesotho
Liberia
Libya
Lithuania
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
(Federated States of)
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Nicaragua
Niger
Nigeria
Niue
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Vincent and the
Grenadines
Sao Tome and Principe
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Solomon Islands
Somalia
South Africa
South Sudan
Sri Lanka
Sudan
Suriname
Swaziland
Taiwan
Tajikistan
Thailand
Timor-Leste
Togo
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Republic of
Tanzania
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian
Republic of)
Viet Nam
Yemen
Zambia
Zimbabwe
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2012. Countries with incidence rates of ≥ 20 cases per 100,000
population. For future updates, refer to http://apps.who.int/ghodata.
3. Have you had frequent or prolonged visits to one or more of the countries listed above with a
high prevalence of TB disease? (If yes, CHECK the countries, above)
Yes No
4. Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional
facilities, long-term care facilities, and homeless shelters)?
5. Have you been a volunteer or health-care worker who served clients who are at increased risk for
active TB disease?
6. Have you ever been a member of any of the following groups that may have an increased incidence of
latent M. tuberculosis infection or active TB disease – medically underserved, low-income, or abusing
drugs or alcohol?
Yes No
Yes No
Yes No
If the answer is YES to any of the above questions, University Health Center requires that you receive TB testing.
If the answer to all of the above questions is NO, no further testing or further action is required.
Signature of Student
(Or Signature of Parent if student is < 18 yrs. old)
Date:
Form Reviewed:
Form Revised: 3/2/2016
click to sign
signature
click to edit
NAME:
UGA
ID#:
Date
of
Birth:
PART II. CLINICAL ASSESSMENT BY HEALTHCARE PROVIDER
Clinicians should review and verify the information in Part I. Persons answering YES to any of the questions in Part I
are candidates for either Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a
previous positive test has been documented.
History of a positive TB skin test or IGRA blood test? (If yes, document below)
Yes
No
History of BCG vaccination? (If yes, consider IGRA if possible.)
Yes
No
1. TB Symptom Check
1
Does the student have signs or symptoms of active pulmonary tuberculosis disease?
Yes
No
*If NO, proceed to 2 and 3. If YES, check below:
Cough (especially if lasting for 3 weeks or longer) with or without sputum production
Coughing up blood (hemoptysis)
Chest pain
Loss of appetite
Unexplained weight loss
Night sweats
Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest
x-ray, and sputum evaluation as indicated.
2. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration,
write “0”. The TST interpretation should be based on mm of induration as well as risk factors.)**
Date Given: / /
Date Read: / /
M D Y M D Y
Result:
mm
of
induration
**Interpretation:
positive
negative
Date Given: / /
Date Read: / /
M D Y M D Y
Result:
mm
of
induration
**Interpretation:
positive
negative
**Interpretation guidelines
>5 mm is positive:
Recent close contacts of an individual with infectious TB
Persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
Organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for >1 month.)
HIV-infected persons
>10 mm is positive:
Recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of time
Injection drug users
Mycobacteriology laboratory personnel
Residents, employees, or volunteers in high-risk congregate settings
Persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renal
failure, certain types of cancer (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or jejunoileal bypass and
weight loss of at least 10% below ideal body weight.
>15 mm is positive:
Persons with no known risk factors for TB who, except for certain testing programs required by law or regulation, would otherwise not be
tested.
NAME:
UGA
ID#:
Date
of
Birth:
3. Interferon Gamma Release Assay (IGRA)
Date Obtained: /_ / (specify method) QFT-GIT T-Spot other_
M D Y
Result: negative positive indeterminate borderline (T-Spot only)
Date Obtained: /
/ (specify method) QFT-GIT T-Spot other_
M D Y
Result: negative positive indeterminate borderline (T-Spot only)
4. Chest x-ray: (Required if TST or IGRA is positive)
Date of chest x-ray: / / Result: normal abnormal
M
D Y
PART III: MANAGEMENT OF POSITIVE TST OR IGRA
All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a
recommendation to be treated for latent TB with appropriate medication. However, students in the following groups
are at increased risk of progression from LTBI to TB disease and should be prioritized to begin treatment as soon as
possible.
Infected with HIV
Recently infected with M. tuberculosis (within the past 2 years)
History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph
consistent with prior TB disease
Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic corticosteroids
equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following organ
transplantation
Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
Have had a gastrectomy or jejunoileal bypass
Weigh less than 90% of their ideal body weight
Cigarette smokers and persons who abuse drugs and/or alcohol
••Populations defined locally as having an increased incidence of disease due to M. tuberculosis, including medically underserved, low-income
populations
Student agrees to receive treatment
Student declines treatment at this time
Required Signature of Healthcare Provider:
Name: Phone:
Address: City, State, Zip Code:
Signature: Date:
Form Created: Administrative Associate
Form Reviewed:
Form Revised: 3/2/2016, 3/31/2016
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Completed 1 June 2021

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