Dear USC Visiting Student,
I would like to extend a warm welcome to the USC Health Science Campus. The Eric Cohen Student Health
Center of USC (ECSHC) will process your health clearance paperwork to help you gain compliance for your
clerkship.
1. Please fill out the attached AAMC immunization form.
• Serologic immunity results are required for measles, mumps, rubella, hepatitis B and
varicella. Proof of immunization is not sufficient. Please attach the full lab results of the
titer tests. For example, in the MMR section, you must complete option 2 and provide full
copies of the serologic immunity.
• For the tuberculosis screening section, you must have one of the following tests. Please
make sure that your test results (valid for one year) will not expire while you are at USC.
□ Two TST (PPD) tests within 364 days of your start date with USC.
OR
□ One IGRA test (either Quantiferon or Tspot) within 364 days of your start date with
USC. Please include full lab results.
 Chest X-rays will only be accepted if you have record of a positive TST (PPD) or
IGRA test. If you are submitting a chest x-ray, please make sure it was done
within 364 days of your start date with USC.
2. Please fill out the highlighted areas of the attached LA County Employee Health Services E2 form.
If you have any questions, please contact the health clearance line at 323-442-5980 or contact the visiting
students’ coordinators Roxie Solano or Bobby Cong by email at [email protected] or [email protected] with
subject title “Visiting Student”.
If you would like to complete your health clearance requirements (i.e. blood tests, TB tests, etc.) at our
health center, please visit http://ecohenshc.usc.edu/health-clearance/prices/ .
Although our time with you will be short, we hope to be of service to you.
Fight On!
Kimberly Tilley, MD
ECSHC Medical Director
Eric Cohen Student Health Center
Keck Medical Center of USC
University of Southern California
1510 San Pablo Street
Suite 104
Los Angeles, CA 90033
AAMC Standardized Immunization Form
Last Name:
First Name:
DOB:
Street Address:
Medical School:
City:
Cell Phone:
State:
Primary Email:
ZIP Code:
Student ID:
Last4 SS#:
I Middle
I
Initial:
MMR (Measles, Mumps, Rubella) - 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose of Rubella;
or serologic proof of immunity for Measles, Mumps and/or Rubella
Option1
Vaccine
MMR
-2 doses of MMR vaccine
Option 2
Measles
-2 doses of vaccine or
positive serology
Mumps
-2 doses of vaccine or
positive serology
Rubella
-1 dose of vaccine or
positive serology
Date
__
MMR Dose #1
_/_/
MMR Dose#2
_ / _ !__
Vaccine or Test
Date
__
__
Measles Vaccine Dose #1
_/_/
Measles Vaccine Dose #2
_/_/
Serologic Immunity (lgG , antibodies, titer)
_ ! _ !_ _
Mumps Vaccine Dose #1
_/_/
Mumps Vaccine Dose #2
_/_/
Serologic Immunity (lgG , antibodies, titer)
_ / _ !_ _
Rubella Vaccine
_/_/
Serologic Immunity (lgG , antibodies , titer)
_/_/
__
0 Copy Attached
__
__
__
0 Copy Attached
0 Copy Attached
Hepatitis 8 Vaccination - 3 doses of vaccine fo llowed by a QUANTITATIVE Hepatitis 8 Surface Antibody (titer) preferably drawn 4-8 weeks after J«1 dose.
If negative, complete a second Hepatitis 8 series followed by a repeat titer. If Hepatitis 8 Surface Antibody is negative after a secondary series, additional testing
including Hepatitis 8 Surface Antigen should be performed. See: http://www.cdc.gov/mmwr/pdf/rr/rr61 03.pdf for more information.
Documentation of Chronic Active Heoatitis 8 is for rotation assianments and counseling purposes only
Primary
Hepatitis 8 Series
Secondary Hepatitis
8 Series
(If no response to primary series)
Hepatitis 8 Vaccine
Non-responder
(If Hepatitis B Surface Antibody
Negative after Primary and Se~~=~
Chronic Active
Hepatitis 8
Hepatitis B Vaccine Dose #1
Date
_ ! _ !_ _
Hepatitis B Vaccine Dose #2
_ / _ !_ _
Hepatitis B Vaccine Dose #3
_/_/
QUANTITATIVE Hep B Surface Antibody
__
_ / _ /__
Hepatitis B Vaccine Dose #4
_/_/
Hepatitis B Vaccine Dose #5
_/_/
Hepatitis B Vaccine Dose #6
_ / _ !_ _
QUANTITATIVE Hep B Surface Antibody
_/_/
Result
miU/ml
Hepatitis B Surface Antigen (if 2"" titer negative)
_ / _ !_ _
0 Copy Attached
Hepatitis B Core Antibody (if 2"" titer negative )
_ / _ !_ _
0 Copy Attached
Hepatitis B Surface Antigen
_/_/
0 Copy Attached
Hepatitis B Viral Load
_/_/
0 Copy Attached
__
__
__
__
Result
miU/ml
I0
Copy
Attached
I0
Copy
Attached
Tetanus-diphtheria-pertussis- One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide date of last Td and Tdap
Date
__
__
Tdap Vaccine (Adacel, Boostrix, etc)
_/_/
T d Vaccine
_/_/
(if more than 10 years since last Tdap)
© 2015 AAMC. May not be reproduced without permission.
Page 1 of 3
AAMC Standardized Immunization Form
Name: - - - - - - - - - - - - - - - - - - - - - - - Date of Birth:
(Last, First, Middle Initial)
(mm/dd/yyyy)
TUBERCULOSIS SCREENING- Results of last (2) TSTs (PPDs) or (1) IGRA blood test are required regardless of prior BCG
status. If you have a history of a positive TST (PPD)~10mm or IGRA please supply information regarding any evaluation and/or
treatment below. You only need to complete ONE section.
Skin test or IGRA results should not exQ.ire during Q.rOQ.osed elective rotation dates
or
must be UQ.dated with the receiving institution Q.rior to rotation.
Tuberculin Screening History
Section A
Negative Skin or
Blood Test
History
-c
Last two skin test
or IGRAs required
c
Use additiona l
rows as needed
~
0
0
Date Placed
Reading
Interpretation
TST#1
_
1_1_ _
_1_1__
- - mm
[D Pos [Ef Neg ro Equiv
TST#2
_
1_1_ _
_1_1__
__mm
ro Pos fET Neg fiT Equiv
TST#3
_
1_1_ _
_1_1__
- - mm
I?" Pos fCJ Neg ~ Equiv
Date
Result
IGRA Blood Test
(Interferon gamma releasing assay)
IGRA Blood Test
(Interferon gamma releasing assay)
:;::;
Date Read
_1_1_ _
~ Negative
0 Copy Attached
_1_1__
~ Negative
0 Copy Attached
_1_1__ fo Negative
0 Copy Attached
Indeterminate
Indeterminate
CJ
(1,)
IGRA Blood Test
0
m
1-
(Interferon gamma releasing assay)
Section B
(1,)
Date Placed
Positive TST
c
_
1_1_ _
Indeterminate
Date Read
_1_1_
0
-(1,)
(1,)
c.
E
0
CJ
(1,)
0
Date
History of
Latent
Tuberculosis,
Positive Skin
Test or
Positive Blood
Test
ns
(1,)
-0..
Positive IGRA Blood Test
_1_1_ _
Chest X-ray
_1_1__
Reading
- - mm
Result
--
0 Copy Attached
0 Copy Attached
fO Yes
Total Duration of prophylaxis?
rcr No
- - Months
- '-'--
Section C
0 Copy Attached
Date
Date of Diagnosis
History of Active
Tuberculosis
IU
Prophylactic Medications for latent TB taken?
Date of Last Annual TB Symptom Questionnaire
(if applicable)
Interpretation
__}__}_
Date of Treatment Completed
__}__}_
0 Copy Attached
Date of Last Annual TB Symptom Questionnaire
(if applicable)
__}__}_
0 Copy Attached
Date of Last Chest X-ray
__}__}_
0 Copy Attached
Varicella (Chicken Pox) -2 doses of vaccine or positive serology
Date
Varicella Vaccine #1
_1_1_ _
Varicella Vaccine #2
_1_1_ _
Serologic Immunity (lgG , antibodies, titer)
© 2015 AAMC. May not be reproduced without permission .
I
I
0 Copy Attached
Page 2 of3
AAMC Standardized Immunization Form
Date of Birth:
Name:
(mm/dd/yyyy)
(Last, First, Middle Initial)
Influenza Vaccine --1 dose annually each fall
Flu Vaccine
_/_/
__
0 Copy Attached
Flu Vaccine
_ ! _ /_ _
0 Copy Attached
Additional Information:
MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER OR INSTITUTIONAL REPRESENTATIVE:
__
Authorized Signature:
Date: _ / _ /
Printed Name:
Off1ce Use Only
Title:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:
(_)
Fax:
(_)
-
Ext:
Email Contact:
*sources:
1. Hepatitis BIn: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds.
13th ed. Washington D.C. Public Health Foundation, 2015
2. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices IACIPl, MMWR, Vol 60(7):1-45
3. Updated CDC Recommendations for the Management of Hepatitis B Virus-Infected Health-Care Providers and Students, MMWR Vol 61(RR03):1-12.
© 2015 AAMC. May not be reproduced without permission.
Page 3 of 3
E2
EMPLOYEE HEALTH SERVICES
PRE-PLACEMENT TUBERCULOSIS HISTORY
AND EVIDENCE OF IMMUNITY
FOR NON-DHS/NON-COUNTY WFM
See GENERAL INSTRUCTIONS on last page.
LAST NAME:
FIRST, MIDDLE NAME:
BIRTHDATE:
E or C#:
E-MAIL ADDRESS:
HOME/CELL PHONE #:
DHS FACILITY:
DEPT/WORK AREA/UNIT:
AGENCY CONTACT PERSON:
AGENCY PHONE #:
JOB CLASSIFICATION:
NAME OF SCHOOL/EMPLOYER/AGENCY/SELF:
In accordance with Los Angeles County, Department of Health Services policy 705.001, Title 8 & 22, and CDC
guidelines all contactors/students/volunteers working at the health facilities must be screened for communicable
diseases prior to assignment. This form must be signed by a healthcare provider attesting all information is true
and accurate OR workforce member may supply all required source documents to DHS Employee Health
Services to verify.
SECTION 1: FOR WORKFORCE MEMBER TO COMPLETE
TUBERCULOSIS SYMPTOM REVIEW – Check all appropriate boxes
No
No
No
No
No
No
Yes Cough lasting more than 3 weeks
No
Yes Excessive fatigue/malaise
Yes Coughing up blood
No
Yes Recent unprotected close contact with a person with
TB
Yes Unexplained/unintended weight loss (> 5 LBS)
Yes Night sweats (not related to menopause)
No
Yes A history of immune dysfunction or are you receiving
chemotherapeutic or immunosuppressant agents
Yes Fever/chills
Yes Excessive sputum
If you have any of the above symptoms, you should meet with your provider to determine whether a chest x-ray is indicated.
SECTION 2: FOR HEALTHCARE PROVIDER TO COMPLETE OR MUST PROVIDE SOURCE DOCUMENTS
TUBERCULIN SKIN TEST RECORD
0.1 ml of 5 tuberculin units (TU) purified protein derivative (PPD) antigen intradermal
Must have 2 negative TST < 12 months of start date.
DATED
PLACED
A
STEP
LOT #
EXP
SITE
DATE
READ
*READ BY
(INITIALS)
RESULT
st
mm
nd
mm
1
2
MANUFACTURER
*ADM BY
(INITIALS)
STATUS
Indicate:
Reactor
Non-Reactor
Converter
If either result is positive, send for CXR and complete Section C below.
OR
B
Negative IGRA: Quantirferon or
Tspot(<12 months)
Date:
LA County
Outside Document
Results
STATUS
If CXR is positive for TB, DO NOT CLEAR for hire/assignment.
Refer Workforce Member for immediate medical care.
C
Positive TST
(no date requirement)
Date:
Results
CXR (at or after date of +TST)
Date:
Results
mm
OR
CONTINUE ON NEXT PAGE
LA County
Outside Document
LA County
Outside Document
STATUS
CONFIDENTIAL
PRE-PLACEMENT TUBERCULOSIS HISTORY AND EVIDENCE OF IMMUNITY
PAGE 2 OF 4
E2
LAST NAME
D
FIRST, MIDDLE NAME
BIRTHDATE
E or C#
Positive IGRA: Quantirferon or
Tspot (no date requirement)
Date:
Results
LA County
Outside Document
CXR (at or after date of +IGRA)
Date:
Results
LA County
Outside Document
History of Active TB with
Treatment
Date:
CXR (after date of completed Tx)
Date:
History of LTBI Treatment
Date:
CXR (at or after date of Tx)
Date:
STATUS
OR
E
Outside Document
months with
STATUS
Outside Document
Results
OR
Outside Document
months with
STATUS
F
Outside Document
Results
AND
IMMUNIZATION DOCUMENTATION HISTORY (MANDATORY)
Titer
Result
Date
G
If not immune, give
Vaccination x 2,
unless Rubella x 1
Titer
Result
Measles
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
Mumps
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
Rubella
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
Varicella
Immune
Non-Immune
Equivocal
Laboratory
confirm of disease
OR
OR
OR
OR
Date
Received
Declined Vaccination
(may be restricted from
hospital/patient care)
Vaccine
Received
X2
X2
X1
X2
OR
Decline only for true
medical contraindication,
must include medical
documentation
OR
Decline only for true
medical contraindication,
must include medical
documentation
OR
Decline only for true
medical contraindication,
must include medical
documentation
OR
Decline only for true
medical contraindication,
must include medical
documentation
AND
Vaccination
H
Date Received
Tetanus-diphtheria (Td) every 10 years
Date of Declination Signed
OR
Acellular Pertussis (Tdap) X 1
AND
CONTINUE ON NEXT PAGE
CONFIDENTIAL
PRE-PLACEMENT TUBERCULOSIS HISTORY AND EVIDENCE OF IMMUNITY
PAGE 3 OF 4
E2
LAST NAME
FIRST, MIDDLE NAME
Vaccination (MANDATORY to offer to
WFM who have potential to be exposed to
blood or body fluid)
Titer
Result
Titer
Date
Hepatitis B
Surface Ab
Titer (HbsAb)
Reactive
anti-HBs
Non-reactive
I
BIRTHDATE
If not reactive,
vaccinate with HepB
series (3 doses)
Date
Received
E or C#
N/A (job duty does not
involve blood or body fluid)
Vaccine
Date
Declination signed
AND/OR
OR
Date
HbcAb/
anti-HBc
Date
HbsAg
Non-reactive
Reactive
Non-reactive
Reactive
AND
Vaccination
J
Date Received
Facility
Received
Date Declination Signed
OR
Seasonal Influenza (one
dose for current season)
Note: Must wear mask during influenza season.
AND
K
Respiratory Fit Test (Complete Form N-NC)
Date:
Pass
Fail
Powered Air Purifying Respirator
N/A (Job duty does not involve airborne precautions)
L
Color Vision (MANDATORY for WFM working
with point of care testing or electrical)
Date:
Pass
Fail
N/A (Job duty does not involve POC testing or electrical )
FOR HEALTHCARE PROVIDER:
I attest that all dates and immunizations listed above are correct and accurate.
Date:
Physician or Licensed Healthcare Professional Signature:
Facility Name/Address:
Print Name:
Phone #:
OR
FOR WORKFORCE MEMBER:
Required source documents attached.
Workforce Member Signature:
Date:
DHS-EHS STAFF ONLY
Date of clearance:
WFM completed pre-placement health evaluation.
Signature:
Print Name:
CONTINUE ON NEXT PAGE
Today’s Date:
E2
LAST NAME
SECTION
CONFIDENTIAL
PRE-PLACEMENT TUBERCULOSIS HISTORY AND EVIDENCE OF IMMUNITY
PAGE 4 OF 4
FIRST, MIDDLE NAME
BIRTHDATE
E or C#
GENERAL INSTRUCTIONS FOR EACH SECTION
TUBERCULOSIS DOCUMENTATION HISTORY
ALL WORKFORCE MEMBER (WFM) SHALL BE SCREENED FOR TB UPON HIRE/ASSIGNMENT
A
B
WFM shall receive a baseline TB screening using two-step Tuberculin Skin Test (TST).
Step 1: Administer TST test, with reading in seven days.
Step 2: After Step 1 reading is negative, administer TST test, with reading within 48-72 hours. If both readings are negative, WFM is
cleared to work. WFM shall receive either TST or IGRA and symptom screening annually.
a. Documentation of negative TST within 12 months prior to placement will be accepted. WFM shall receive a one-step TST with
reading within 48-72 hours. If result is negative, WFM is cleared to work;
b. Documentation of negative two-step TST within 12 months prior to placement will be accepted. WFM is cleared to work.
If TST is positive, record results and continue to Section C.
WFM shall receive a baseline TB screening using a single blood assay for M. tuberculosis (IGRA). If negative result, WFM is cleared to
work. WFM shall receive either TST or IGRA and symptom screening annually.
a. Documentation of negative IGRA within 12 months will be accepted. WFM is cleared to work.
If IGRA is positive, record results and continue to Section D.
TST POSITIVE RESULTS
If CHEST X-RAY IS POSITIVE, DO NOT CLEAR FOR HIRE/ASSIGNMENT, AND
REFER WORKFORCE MEMBER FOR IMMEDIATE MEDICAL CARE
C
D
E
F
If TST is positive during testing in Section A or C above, send for a chest x-ray (CXR). If CXR is negative, WFM is cleared to work.
Documentation of negative CXR at or after first positive TST will be accepted for clearance to work as long as TB symptom screening is
negative.
If IGRA is positive during testing in Section D above, send for a CXR. If CXR is negative, WMF is cleared to work. Documentation of
negative CXR at or after first positive IGRA will be accepted for clearance to work as long as TB symptom screening is negative.
If WFM have a documented history of active TB, send for a chest x-ray (CXR). If CXR is negative, WFM is cleared to work.
Documentation of negative CXR after active TB treatment will be accepted for clearance to work as long as TB symptom screening is
negative.
If WFM have a documented history of latent tuberculosis infection (LTBI) treatment, send for a chest x-ray (CXR). If CXR is negative,
WFM is cleared to work. Documentation of negative after LTBI treatment will be accepted for clearance to work as long as TB symptom
screening is negative.
IMMUNIZATION DOCUMENTATION HISTORY
Documentation of immunization or adequate titers will be accepted. If WFM is not immune against communicable diseases as listed in this section, WFM shall
be immunized (unless medically contraindicated). WFM who declines the vaccination(s) must sign the mandatory declination form. WFM who declines the
vaccination(s) may be restricted from patient care areas of the hospital or facility. If WFM is non-immune or decides at a later date to accept the vaccination,
DHS or WFM contract agency will make the vaccination available.
Documentation of laboratory evidence of immunity or laboratory confirmation of disease will be accepted OR documentation of two doses
(live measles, mumps and varicella) and one dose of live rubella virus vaccine. Measles vaccine shall be administered no earlier than one
month (minimum 28 days) after the first dose. Mumps second dose vaccine varies depending on state or local requirements. Varicella
G
doses shall be at least 4 week between doses for WFM. If Equivocal, WFM needs either vaccination or re-draw with positive titer. DHSEHS must be notified if WFM does not demonstrate evidence of immunity.
Td – After primary vaccination, Td booster is recommended every 10 years. If unvaccinated WFM, primary vaccination consists of 3
doses of Td; 4-6 weeks should separate the first and second doses; the third dose should be administered 6-12 months after the second
H
dose.
Tdap should replace a one time dose of Td for HCP aged 11 and up.
All WFM who have occupational exposure to blood or other potentially infectious materials shall have a documented post vaccination
antibody to Hepatitis B virus, HBsAb (anti-HBs). Hepatitis B vaccine series is available to WFM. Non-responders should be considered
I
susceptible to HBV and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for
any known or probable parenteral exposure to HBsAg positive blood.
Seasonal influenza is offered annually to WFM when the vaccine becomes available.
J
This form and its attachment(s), if any, such as medical records shall be maintained and filed at non-DHS/non-County workforce member’s
School/Employer. The School/Employer shall verify completeness of DHS-Employee Health Services (EHS) form(s) and ensure confidentiality of nonDHS/non-County WFM health information.
Upon request by DHS-EHS, the non-DHS/non-County WFM School/Employer shall have this form and its attachment(s) readily available within four (4)
hours.
All workforce member health records are confidential in accordance with federal, state and regulatory requirements.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or
requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we
are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by
GINA, includes an individual’s family medical history, the results of an individual’s family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. 29 C.F.R. Part 1635
Rev 11/2015