UCLA Incoming Student Health Form – 2017-2018 Academic Year
If you do not have a copy of your official immunization record or lab reports (foreign record must be translated into English), please
have these sections completed legibly in English by a licensed medical professional unrelated to the student.
Student Information: Student ID#: _______________ Date of Birth: ___________
Last Name: _________________________ First Name: ________________ Middle Initial: __________
Address ________________________________________________________ Age at Enrollment: ______
City _________________________ State ________ Zip Code _________ Country _______________
_
Student Status: ______________
Telephone: _______________ Emergency Telephone: _____________
Quarter/Year Entering: _________________ International Student
REQUIRED IMMUNIZATIONS FOR ALL STUDENTS
Measles-MumpsRubella (MMR)
Two (2) doses
required; first dose
on or after 1st
birthday OR positive
titer
Laboratory evidence of Positive immune titers .
Dose #1 ____/_____/______ (MM/DD/YR)
Dose #2 ____/_____/______ (MM/DD/YR) Measles Titer Result:
Positive
Negative ____/_____/______ (MM/DD/YR)
Mumps Titer Result:
Positive
Negative____/_____/______ (MM/DD/YR)
Rubella Titer Result:
Positive
Negative ____/_____/______ (MM/DD/YR)
(*If any titer is negative or equivocal, two vaccinations are required. Attach copy of all lab reports)
Varicella (Chicken
Pox)
Two (2) doses
required; first dose
on or after 1st
birthday OR positive
titer
(Tdap) Tetanus,
Diptheria &
Pertussis (e.g.
Dose #1 ____/_____/______ (MM/DD/YR)
Positive Varicella Antibody ____/_____/______ (MM/DD/YR)
Dose #2 ____/_____/______ (MM/DD/YR) (attach copy of lab report)
(*If Varicella antibody titer is negative or equivocal, two vaccinations are required)
Date ____/_____/______ (MM/DD/YR)
Adacel/Boostrix)
1 dose after age 7
Meningococcal
conjugate-(Serogroups A, C,
Y, & W-135)
Only for students
age 21 or younger:
1 dose on or after
age 16
Date ____/_____/______ (MM/DD/YR)
Name of vaccine:____________________
Menactra®, MenHibrix® or Menveo® vaccines are preferred.
If you are Healthcare Professional Student (Medical/Dental/Nursing/Social Welfare) OR if you answered “YES” to any of the
questions on the Tuberculosis Screening Questionnaire on the Ashe Secure Portal, complete the Tuberculosis (TB) Testing
section
Tuberculosis (TB) Testing
If no history of positive TB skin
test, two separate skin tests OR
one IGRA blood test is required.
Skin tests must be placed at
least one week apart.
2 Step Tuberculin Skin Test
(PPD)
Interferon Gamma Release Assay (IGRA) within 6 months prior to matriculation
*Recommended if the student had prior history of BCG (attach copy of lab report)
Step 1 - Tuberculin Skin Test
(PPD) within 12 months prior to
matriculation:
Specify Method (Select one):
QFT-G
QFT‐GIT
T‐SPO
Date Placed:
_____/_____/_____ Date Read:
_____/_____/_____ Result
(mm): ______
Positive:
Negative:
Date of Test:
/
Other
/_
Result (Select one):
Negative
Positive
Indeterminate
Borderline (T-Spot only)
Step 2 - Tuberculin Skin Test
(PPD) within 6 months prior
to matriculation:
Date Placed:
_____/_____/_____ Date Read:
_____/_____/_____ Result
(mm): ______
Positive:
Negative:
Chest X-Ray within 6 months
prior to matriculation (Required
Chest X-Ray Date: _____/_____/_____ Normal:
if positive skin test or IGRA
result)
History of INH (Isoniazid) Treatment or other anti-tubercular drugs? (Select one):
If Yes, Date Initiated: _____/_____/_____
Abnormal:
Yes
(Attach copy of chest x-ray report)
No
Date Completed: _____/_____/_____
Type of treatment:
ADDITIONAL REQUIREMENTS FOR ALL HEALTHCARE PROFESSIONAL SCHOOL STUDENTS (MEDICAL/NURSING/DENTAL/SOCIAL WELFARE)
Hepatitis B Immunity
All students must have a series of three
Hepatitis B vaccinations (initial dose,
dose two at 1 month, and dose three at
6 months). A post-vaccine surface
antibody titer (to demonstrate
immunity) is required one month after
3rd vaccine dose.
Dose #1 ____/_____/______ (MM/DD/YR)
Dose #2 ____/_____/______ (MM/DD/YR)
Dose #2 ____/_____/______ (MM/DD/YR)
Hep B surface antibody titer: Reactive:
Non-Reactive:
Date: _____/_____/_____
*If antibody non-reactive, Hepatitis B surface antigen is required prior to repeat series.
Hep B surface antigen titer: Reactive:
Non-Reactive:
Date: _____/_____/_____
If Hep B surface antigen is negative, repeat Hep B series required and repeat titer one month after series completion.
Dose #4 ____/_____/______ (MM/DD/YR)
Dose #5 ____/_____/______ (MM/DD/YR)
Dose #6 ____/_____/______ (MM/DD/YR)
2nd Hep B surface antibody titer: Reactive:
Non-Reactive:
Date: _____/_____/_____
*If repeat Hep B surface antibody is non-reactive, student will need to schedule an appointment at UCLA Student Health
for evaluation.
Tetanus, Diptheria (Td) or Tdap
1 dose in last 10 years
Date ____/_____/______ (MM/DD/YR)
for
Tetanus, Diptheria (Td)
Tdap
Medical Professional Completing this Form:
Name:
Professional Title:
License No.:
Address:_
City
State:
Phone:
Zip:
FAX:
1. Once you have completed this form, log back into the Ashe Secure Patient Portal
3. Select “Forms” from the options on the left side of the page.
4. Complete the forms labeled “IMMUNIZATION COMPLIANCE/HEALTH CLEARANCE.”
5. Enter your immunization history where prompted.
6. Upload a copy of this form as your supporting document