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Please complete this form OR use as a guide. All supporting documents are required.
PLEASE PRINT DOCUMENT IN COLOR
University of Hawai’i at Hilo
The Daniel K. Inouye College of Pharmacy
Tuberculosis & Immunization Record
Last Name: ____________________ First Name:____________________ Middle Name:______________________
Birthdate: ______________________SSN/UH ID#: __________________
The State of Hawaii mandates that certain health requirements be met for entrance to post-secondary educational
institutions. (Hawaii Administration Rules, DOH Title 11, Chapter 157). In addition to these requirements,
The Daniel K. Inouye College of Pharmacy (DKICP) also requires all students to comply with the health requirements
of its affiliated experiential sites.
Please review Tuberculosis & Immunization Record Frequently Asked Questions for further guidance.
Please contact Christina Method at DKICP Office of Experientials if you have any questions.
Email: [email protected] Phone: (808) 932-7709
TUBERCULOSIS (TB) – The state of Hawaii does not accept QuantiFERON results as proof of
TB clearance.
Attach a copy of your TB record OR have a physician/clinician sign off on this form
• A 2-Step Mantoux skin test must be performed between 8/23/14 - 8/24/15 within the United
States or its territories.
• Do NOT receive an MMR vaccination before or during a PPD skin test. Always do PPD
skin test first.
• A 2-Step requires that you get two TB skin tests; the second one should be administered AT
LEAST 7 days after the 1st PPD is given.
• If your PPD test results are between 5 mm and 9 mm, you must have another PPD placed in
3 months.
• If you test Positive, you will be required to take a Chest X-ray. Chest X-Rays are required,
no exceptions. Date of positive reading including the mm size is required. Please, also
provide a copy of the CXR report.
OR
If you have a History of Positive TB Screenings, you MUST complete the following:
1. Provide the date and mm size of a Positive PPD reading and documentation in English.
2. Provide a current Chest X-ray report (dated between 8/23/14 – 8/24/15). Chest X-rays are
required, no exceptions.
Date Given
Date Read
1st
PPD
____/____ /____
____/____ /____
OR
Positive PPD
Date:
____/____ /____
Test
Results
mm
mm
Verified By:
Signature/Print
Name/Title/Office
2nd
PPD
Date Given
Date Read
____/____ /____
____/____ /____
Chest X-Ray Date:
Test
Results
Verified By:
Signature/Print
Name/Title/Office
mm
____/____ /____
 Positive
Negative
Last Revised 5/20/15
Student Name: _____________________________ Birthdate: _____________ SSN/UH ID#: _________________
MEASLES/RUBEOLA, MUMPS, & RUBELLA (MMR)
Attach a copy of your lab results to this form
• Measles/Rubeola, Mumps, and Rubella (MMR) IgG Quantitative Titers are required. No exceptions.
• If any of your MMR titers are Negative or Equivocal you need to provide documentation of two initial MMR
vaccinations AND one booster vaccination that was received after negative titer.
• Do NOT receive MMR vaccinations before or during a TB/PPD reading. Complete the TB/PPD reading first.
Titer Date Collected
Measles/
Rubeola
Verified By:
Signature/Print
Name/Title/Office
Titer Result
IF any of your MMR titers are
Negative/Equivocal you need to provide
documentation of two initial MMR
vaccinations AND one booster vaccination
that was received after your negative titer
 Positive/Reactive
_____/_____ /_____
 Equivocal
 Negative/Non-reactive
MMR 1: _____/_____ /_____
 Positive/Reactive
Mumps
_____/_____ /_____
 Equivocal
MMR 2: _____/_____ /_____
 Negative/Non-reactive
MMR Booster: _____/_____ /_____
 Positive/Reactive
Rubella
_____/_____ /_____
 Equivocal
 Negative/Non-reactive
VARICELLA (Chicken Pox)
Attach a copy of your lab results to this form
• Varicella IgG Quantitative Titer is required for clearance. No exceptions.
• If your Varicella titer is Negative or Equivocal you need to provide documentation of two Varicella
vaccinations, the second vaccination must be received after negative titer.
Titer Date Collected
Varicella
Verified By:
Signature/Print
Name/Title/Office
_____/_____ /_____
Titer Result
IF Negative/Equivocal Titers
 Positive/Reactive
Varicella 1: _____/_____ /_____
 Equivocal
Varicella 2: _____/_____ /_____
 Negative/Non-reactive
Varicella Booster: _____/_____ /_____
TETANUS/DIPHTHERIA/PERTUSSIS
Attach a copy of your immunization record OR have a physician/clinician sign off on this form
• CDC requires completion of three Tetanus, Diphtheria, and Pertussis vaccinations.
• Tdap must be received after 16 years of age and within 10 years of 8/24/15.
• Proof of two past immunizations are required (childhood immunizations include DT, DTaP or IDT) or if you
do not have a documented history of Tetanus, Diphtheria, Pertussis, please get a Tdap first, wait four weeks,
get a Td booster, then wait 6 months and get a second Td booster.
Tdap
Within 10 years, after age
16
Verified By:
Signature/Print
Name/Title/Office
Tetanus
(DT, DTaP, IDT, Td, Tdap)
Verified By:
Signature/Print
Name/Title/Office
Tetanus
(DT, DTaP, IDT, Td, Tdap)
Type: Tdap_____
Type _____________
Type ____________
____ /_____ /_____
____ /_____ /_____
____ /_____ /_____
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Verified By:
Signature/Print
Name/Title/Office
Student Name: _____________________________ Birthdate: _____________ SSN/UH ID#: _________________
HEPATITIS B
Attach copy of lab results to this form
• Hepatitis B AB Quantitative Titer is required, unless you completed the vaccination series
prior to January 1, 1998, then do not do a titer.
• Titer should be obtained 3 to 4 weeks after 3rd HepB Vaccination.
• If your HepB titer is Negative or Equivocal, you will need to provide documentation of the initial three
vaccine series AND one booster vaccination that was received after negative titer.
Hep B Series
1st Dose
Verified By:
Signature/Print
Name/Title/Office
_____/_____ /_____
Hep B Series
3rd Dose
5 months after 2nd
Dose
Verified By:
Signature/Print
Name/Title/Office
_____/_____ /_____
Date Titer Collected
3-4 weeks after Series
#1 is completed
Hep B Titer
Hep B Series
2nd Dose
One month after 1st
Dose
_____/_____ /_____
_____/_____ /_____
Titer Result
Hep B Booster
If Hep B Titer is equivocal or negative you must
receive a booster vaccine
Positive/Reactive
Verified By:
Signature/Print
Name/Title/Office
Equivocal
Negative/Non-reactive
Verified By:
Signature/Print
Name/Title/Office
_____/_____ /_____
Note: Some rotation sites will only accept positive titers. In the event you are placed at one of these sites you will need to re-titer.
DKICP will accept proof of immunization and/or disease history if a health care provider completes the section below.
This includes the provider’s name, signature, date, address and phone number.
Appropriate supporting documentation, including x-ray reports (if applicable) and blood test titer lab reports
still need to be attached.
PRINT or TYPE Name of Physician/Clinician
Signature
Physician/Clinician Address
State
City
Date
Zip Code
Keep a copy for your records
Page 3 of 3
Phone No.