Standard Vaccination Form PDF Details

In today's increasingly global and interconnected environment, ensuring the health and safety of medical students and healthcare professionals has never been more critical. The Association of American Medical Colleges (AAMC) Standardized Immunization Form plays a pivotal role in this endeavor, serving as a comprehensive tool for documenting the immunization status of individuals entering the medical field. This form covers a wide range of vaccinations and screenings, from Measles, Mumps, and Rubella (MMR) to more recent requirements like the COVID-19 vaccine series, including booster doses. It also includes protocols for Tetanus-diphtheria-pertussis (Tdap), Varicella, Influenza, and Hepatitis B vaccinations, alongside Tuberculosis screening requirements, tailored to address the specific risks healthcare workers face. The form not only enables medical schools and healthcare facilities to comply with state laws and institutional policies but also underscores the importance of maintaining a safe and healthy environment for both providers and patients. By detailing multiple vaccination options, including serologic proof of immunity and quantitative immunological responses, the AAMC Standardized Immunization Form ensures a thorough and adaptable approach to immunization documentation, reflecting contemporary practices and advancements in medical science.

QuestionAnswer
Form NameStandard Vaccination Form
Form Length4 pages
Fillable?Yes
Fillable fields191
Avg. time to fill out39 min 16 sec
Other namesvaccine form for school, standard immunization form, printable vaccination record, new jersey immunization record form

Form Preview Example

 

 

 

 

AAMC Standardized Immunization Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

First Name:

 

 

 

 

 

 

Middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB:

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical School:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell Phone:

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Email:

 

 

 

ZIP Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

Student ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose

Copy

 

 

of Rubella; or serologic proof of immunity for Measles, Mumps and/or Rubella. Choose only one option.

 

 

 

 

 

 

 

Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Option 1

Vaccine

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR

MMR Dose #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-2 doses of MMR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

vaccine

MMR Dose #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Option 2

Vaccine or Test

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

Measles

Measles Vaccine Dose #1

 

 

 

 

Serology Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles Vaccine Dose #2

 

 

 

Titer Results:

 

 

Positive

Negative

 

 

 

 

-2 doses of vaccine or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualitative

 

 

 

 

 

 

 

 

 

 

 

positive serology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Serologic Immunity (IgG antibody titer)

 

 

 

Titer Results:

 

 

 

 

 

IU/ml

 

 

 

 

 

 

 

 

 

 

 

Quantitative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mumps

Mumps Vaccine Dose #1

 

 

 

 

Serology Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mumps Vaccine Dose #2

 

 

 

Titer Results:

 

 

Positive

Negative

 

 

 

 

-2 doses of vaccine or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualitative

 

 

 

 

 

 

 

 

 

positive serology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Serologic Immunity (IgG antibody titer)

 

 

 

Titer Results:

 

 

 

 

 

IU/ml

 

 

 

 

 

 

 

 

 

 

 

Quantitative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubella

 

 

 

 

 

 

Serology Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubella Vaccine

 

 

 

Qualitative

 

 

Positive

Negative

 

 

 

 

-1 dose of vaccine or

 

 

 

Titer Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

positive serology

Serologic Immunity (IgG antibody titer)

 

 

 

Quantitative

 

 

 

 

 

IU/ml

 

 

 

 

 

 

 

Titer Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tetanus-diphtheria-pertussis One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide dates of last Td and Tdap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap Vaccine (Adacel, Boostrix, etc)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Td Vaccine (if more than 10 years since last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella (Chicken Pox) - 2 doses of vaccine or positive serology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella Vaccine #1

 

 

 

 

Serology Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella Vaccine #2

 

 

 

Titer Results:

 

 

Positive

Negative

 

 

 

 

 

 

 

 

 

Qualitative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Serologic Immunity (IgG antibody titer)

 

 

 

Titer Results:

 

 

 

 

 

IU/ml

 

 

 

 

 

 

 

 

 

 

 

Quantitative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Influenza Vaccine - 1 dose annually each fall

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of last dose

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Flu Vaccine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVID-19 Vaccine - primary series of two (2) doses and booster dose

 

 

Date

Company or Trade Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVID-19 Vaccine #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVID-19 Vaccine #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVID-19 Booster Bivalent Vaccine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

© 2023 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution.

 

 

 

 

 

 

Page 1 of 4

AAMC Standardized Immunization Form

Name:

 

 

Date of Birth:

 

 

 

 

 

(Last, First, Middle Initial)

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B Vaccination - 3 doses of Engerix-B, PreHevbrio, Recombivax HB or Twinrix vaccines or 2 doses of Heplisav-B vaccine followed by a

Copy

 

QUANTITATIVE Hepatitis B Surface Antibody test drawn 4-8 weeks after last vaccine dose. A test titer >10mIU/mL is positive for immunity. If the test result is

 

repeat titer test 4-8 weeks after the last vaccine dose. If a single additional vaccine dose does not elicit a positive test result, administer additional vaccine doses

Attached

 

negative, CDC guidance recommends that HCP receive one or more additional doses of Hepatitis B vaccine up to completion of a second series, followed by a

 

 

 

 

to complete the second series using the schedule approved for the primary series of a given product. If the Hepatitis B Surface Antibody test is negative (<10

 

 

 

 

mIU/mL) after receipt of 2 complete vaccine series, a “non-responder” status is assigned. See: http://dx.doi.org/10.15585/mmwr.rr6701a1 for additional

 

 

 

 

information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3-dose vaccines (Energix-B, PreHevbrio,

3 Dose Series

 

2 Dose Series

 

 

 

 

 

 

 

Recombivax HB, Twinrix) or

 

 

 

 

 

 

 

 

2-dose vaccine (Heplisav-B)

 

 

 

 

 

 

 

 

 

 

 

 

Primary

Hepatitis B Vaccine Dose #1

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B Series

 

 

 

 

 

 

 

 

 

Hepatitis B Vaccine Dose #2

 

 

 

 

 

 

 

 

Heplisav-B only requires two

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

doses of vaccine followed by

Hepatitis B Vaccine Dose #3

 

 

 

 

 

 

 

 

 

 

 

 

antibody testing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUANTITATIVE Hep B Surface

 

 

 

 

mIU/ml

 

 

 

 

 

 

Antibody Test

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional doses of

 

3 Dose Series

 

2 Dose Series

 

 

 

 

 

Hepatitis B Vaccine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B Vaccine Dose #4

 

 

 

 

 

 

 

 

 

 

 

Only If no response to

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B Vaccine Dose #5

 

 

 

 

 

 

 

 

 

 

 

 

primary series

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heplisav-B only requires two

Hepatitis B Vaccine Dose #6

 

 

 

 

 

 

 

 

 

 

 

doses of vaccine followed by

 

 

 

 

 

 

 

 

 

 

 

 

 

antibody testing

QUANTITATIVE Hep B Surface

 

 

 

 

mIU/ml

 

 

 

 

 

 

Antibody Test

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the Hepatitis B Surface Antibody test is negative (titer less than 10 mIU/mL) after a

 

 

 

 

Hepatitis B Vaccine

primary and repeat vaccine series, vaccine non-responders should be counseled and

 

 

 

 

evaluated appropriately. Certain institutions may request signing an “acknowledgement

 

 

 

 

 

Non-responder

 

 

 

 

 

of non-responder status” document before clinical placements.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Documentation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Some institutions may have additional requirements depending upon rotation, school requirements or state law. Examples include meningitis vaccine which is mandated in some states if you live in dormitory style housing. If you will be participating in an international experience, you may also be required to provide proof of vaccines such as yellow fever or typhoid.

Vaccination, Test or Examination

Date

Result or Interpretation

 

 

 

 

 

 

 

 

 

Physical Exam (if required)

© 2023 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution.

Page 2 of 4

AAMC Standardized Immunization Form

Name:

Date of Birth:

 

(Last, First, Middle Initial)

 

(mm/dd/yyyy)

TUBERCULOSIS (TB) SCREENING – All U.S. healthcare personnel are screened pre-placement for TB. Results of the last (2) TB Skin Tests (TSTs)) or (1) IGRA blood test are required regardless of prior BCG status. The 2-step TST protocol must have been placed within the past 12 months prior to clinical duties, and must have been performed in the U.S. The second TST must be placed at least 1 week after the first TST read date. If you have a history of a positive TST (PPD)>10mm or a positive IGRA blood test, please supply information regarding any evaluation and/or treatment below. You only need to complete ONE section, A or B.

Skin test or IGRA results should not expire during proposed elective rotation dates

or

must be updated with the receiving institution prior to rotation.

Tuberculosis Screening History

Please complete only one TB section based on your history

Section A

History of

Negative TB Skin

Test or Blood

Test

T-spots or QuantiFERON TB Gold blood tests for tuberculosis

Use additional rows as needed

Section B

History of

Positive Skin

Test or

Positive Blood

Test

 

Date Placed

Date Read

 

 

 

Result

 

 

 

Interpretation

TST #1

 

 

 

 

 

 

 

mm

 

Pos Neg Equiv

 

 

 

 

 

 

 

 

 

 

 

TST #2

 

 

 

 

 

 

 

mm

 

Pos Neg Equiv

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

Result

 

 

 

 

QuantiFERON TB Gold or T-Spot

 

 

Positive

Negative

Indeterminate

(Interferon Gamma Releasing Assay)

 

 

 

 

 

 

 

 

 

 

 

 

 

QuantiFERON TB Gold or T-Spot

 

 

Positive

Negative

Indeterminate

(Interferon Gamma Releasing Assay)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Placed

Date Read

 

 

 

Result

 

 

 

 

Positive TST

 

 

 

 

 

 

 

mm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

Result

 

 

 

 

QuantiFERON TB Gold or T-Spot

 

 

Positive

 

Negative

Indeterminate

(Interferon Gamma Releasing Assay)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chest X-ray*

 

 

*Provide documentation or result

 

 

 

 

 

 

 

Treated for latent TB infection (LTBI)?

 

 

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Last Annual TB Symptom Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

© 2023 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution.

Page 3 of 4

AAMC Standardized Immunization Form

Name:

Date of Birth:

 

(Last, First, Middle Initial)

 

(mm/dd/yyyy)

Additional Information

MUST BE SIGNED BY A LICENSED HEALTHCARE PROFESSIONAL OR DESIGNEE:

Healthcare Professional

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

Printed Name:

 

 

 

 

 

 

 

Office Use Only

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address Line 1:

 

 

 

 

 

 

 

 

Address Line 2:

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

Phone:

(

 

)

-

Ext:

 

 

 

 

 

 

 

 

 

 

 

Fax:

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Contact:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Sources:

1.Hepatitis B In: 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 (ACIP), MMWR, Vol 60(7):1-45

3.CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, MMWR, Vol 62(RR10):1-19

4.Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, MMWR Vol 67(1):1-31

5.Sosa LE, Nijie GL, Lobato MN, et.al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from National Tuberculosis Controllers Association and CDC, 2019. MMWR2019;68:439-443. https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s cid+mm6819a3 w

© 2023 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution.

Page 4 of 4

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Inside the part Mumps doses of vaccine or, Mumps Vaccine Dose, Mumps Vaccine Dose, Serology Results, Qualitative Titer Results, Positive Negative, Rubella dose of vaccine or, Serologic Immunity IgG antibody, Quantitative Titer Results, IUml, Rubella Vaccine, Serology Results, Qualitative Titer Results, Positive Negative, and Serologic Immunity IgG antibody enter the particulars the program demands you to do.

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Write down the main details in Influenza Vaccine dose annually, Date of last dose, Flu Vaccine, COVID Vaccine primary series of, Date, Date, Company or Trade Name, COVID Vaccine, COVID Vaccine, COVID Booster Bivalent Vaccine, AAMC May be reproduced and, and Page of segment.

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Identify the rights and responsibilities of the parties inside the part AAMC Standardized Immunization Form, Name, Last First Middle Initial, Date of Birth, mmddyyyy, Hepatitis B Vaccination doses of, Copy Attached, Primary Hepatitis B Series, HeplisavB only requires two doses, Additional doses of Hepatitis B, Only If no response to primary, HeplisavB only requires two doses, dose vaccines EnergixB PreHevbrio, Hepatitis B Vaccine Dose, and Hepatitis B Vaccine Dose.

nj imm 8 AAMC Standardized Immunization Form, Name, Last First Middle Initial, Date of Birth, mmddyyyy, Hepatitis B Vaccination   doses of, Copy Attached, Primary Hepatitis B Series, HeplisavB only requires two doses, Additional doses of Hepatitis B, Only If no response to primary, HeplisavB only requires two doses, dose vaccines EnergixB PreHevbrio, Hepatitis B Vaccine Dose, and Hepatitis B Vaccine Dose blanks to fill

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