Wednesday, June 02, 2021

Requirement Explanation
Package Name Category Name Student Notes URL Item Name Field Name
University of Michigan Handbook Certificate You must electronically sign the below Handbook Certificate annually. You may not Handbook Certificate Document
Tracking Package sign it before 4/22.
Expiration Date

Complete Form

Technical Standards You must electronically sign the below Technical Standards annually. You may not Technical Standards Document
sign it before 4/22.
Expiration Date

Complete Form

Authorization to You must electronically sign the below Authorization to Disclose Statement. You Authorization to Disclose Document
Disclose Statement may sign the refusal to disclose statement instead, but it can adversely affect your Statement
clinical placement ability. Your statement must be updated annually. It may not be Expiration Date
updated before 4/22. Complete Form

Refusal to Disclose Document

Statement
Expiration Date

Complete Form

MMR You must submit A OR B: Repeat MMR Dose Document

A) 2 doses of the MMR Vaccine. After the first dose you will be compliant for 1 Date
month to allow time to receive the second dose. Mumps Titer Results
B) Positive titers for Measles, Mumps, and Rubella. If any titer is not immune then Document
you must submit 1 repeat dose and positive repeat titers for the non-immune
titers. Date

Measles Titer Results

To see what is required on your documentation, please see
http://forms.complio.com/ReviewStandards/3.pdf Document

Date

Rubella Titer Results

Document

Date

MMR Dose 2 Document

Date

Repeat Measles Titer Results

Document

Date

Repeat Rubella Titer Results

Document

Date

Repeat Mumps Titer Results

110 Sixteenth Street 8th Floor Denver, Colorado 80202 Phone: 303-573-1130 Fax: 303-573-1779 American DataBank
University of Michigan MMR You must submit A OR B: Repeat Mumps Titer Document
Tracking Package
A) 2 doses of the MMR Vaccine. After the first dose you will be compliant for 1 Date
month to allow time to receive the second dose. MMR Dose 1 Document
B) Positive titers for Measles, Mumps, and Rubella. If any titer is not immune then Date
you must submit 1 repeat dose and positive repeat titers for the non-immune titer
Varicella You must submit A OR B: Varicella Titer Results

A) 2 doses of the Varicella Vaccine. After the first dose you will be compliant for 1 Document
month to allow time to receive the second dose. Date
B) Positive varicella titer. If your titer is not immune then you must submit 1 Repeat Varicella Titer Results
repeat dose and a positive repeat titer.
Document
To see what is required on your documentation, please see
Date
http://forms.complio.com/ReviewStandards/3.pdf
Varicella Dose 1 Document

Date

Varicella Dose 2 Document

Date

Repeat Varicella Dose Document

Date

Hepatitis B You must submit A OR B: Repeat Hepatitis B Titer Results

A) 3 doses of the hepatitis B Vaccine. After the first dose you will be compliant for Document
1 month to allow time to receive the second dose. After the second dose you will Date
be compliant for 5 months to allow time to receive the third dose.
Hepatitis B Dose 3 Document
B) Positive hepatitis B titer. If your titer is not immune then you must submit 1
repeat dose and a positive repeat titer. Date

Hepatitis B Titer Results

To see what is required on your documentation, please see
http://forms.complio.com/ReviewStandards/3.pdf Document

Date

Hepatitis B Dose 2 Document

Date

Repeat Hepatitis B Dose 1 Document

Date

Hepatitis B Dose 1 Document

Date

Tuberculosis If you test negative for tuberculin exposure, you must submit either a PPD annually http://www.umichcomplia QuantiFERON / T-Spot - Document
or a QuantiFERON / T-Spot every three years. If submitting a PPD, you may use the nce.com/forms/UMichTBS every 3 years
below form. kinTest.pdf Result

Date
If you test positive for tuberculin exposure, you must submit a chest x-ray from the
last three years. Annually after this 3 year expiration, you may submit a TB Expiration Date
Clearance Letter.
Chest X-Ray - every 3 Document
Whichever test you have, it must be received between April 22nd and September years
Result
30th.
110 Sixteenth Street 8th Floor Denver, Colorado 80202 Phone: 303-573-1130 Fax: 303-573-1779 American DataBank
University of Michigan Tuberculosis If you test negative for tuberculin exposure, you must submit either a PPD annually http://www.umichcomplia Chest X-Ray - every 3 Date
Tracking Package or a QuantiFERON / T-Spot every three years. If submitting a PPD, you may use the nce.com/forms/UMichTBS years
below form. kinTest.pdf TB Clearance Letter Document

Date
If you test positive for tuberculin exposure, you must submit a chest x-ray from the
last three years. Annually after this 3 year expiration, you may submit a TB Expiration Date
Clearance Letter.
Annual PPD Document
Whichever test you have, it must be received between April 22nd and September
Result
30th.
Date

Expiration Date

Tdap You must submit a Tdap received at or after age 10. If your Tdap is more than 10 Td Document
years old then you also must submit a Td booster from within the last 10 years.
Date
Your form needs to clearly indicate which vaccination was received. The state of Expiration Date
Michigan form is not always clear on which vaccine was received, so the received
vaccine will need circled on your form if it is otherwise ambiguous. Tdap Document

To see what is required on your documentation, please see Date

http://forms.complio.com/ReviewStandards/1.pdf
CPR You must submit your American Heart Association BLS CPR card here. Please note American Heart Document
that the American Red Cross is not an acceptable provider for this. Your card must Association BLS CPR Card
be received after April 21st. If your card is received outside of this timeframe and Date
has more than 1 year left, please see your school for an override. Expiration Date

Influenza You must submit a flu shot for the current flu season. Your flu shot must be http://umichcompliance.c Flu Shot Document
received August 15th or later to be applied to the current flu season. Your flu shot om/forms/VerificationOfA
must be submitted by November 29th. nnualFluShot.pdf Date

Expiration Date

Background Check You must order a background check through American DataBank. Your results will American DataBank Document
be uploaded here once complete. If your school is approving an alternative Background Check
screening on your behalf, they may enter it for you here. Date

Results

Alternative Screening Date

Results

Drug Screen DO NOT ORDER YOUR DRUG SCREEN UNTIL INSTRUCTED TO DO SO BY YOUR American DataBank Drug Document
SCHOOL: Screen
Date
You must order a drug screen through American DataBank annually. Your results Expiration Date
will be uploaded here once complete.
Results

State of Residence You must submit State of Residence Change. http://www.umichcomplia State of Residence Document
Change nce.com/forms/Undergrad Change
uateStateOfResidenceCha Date
ngeNotification.pdf Expiration Date

COVID-19 Vaccine You must answer the COVID-19 Vaccine question and if you have received your COVID-19 Vaccine Document
COVID-19 Vaccine, please submit your doses here. Question
Date

Have you received

your COVID-19
Vaccine?

110 Sixteenth Street 8th Floor Denver, Colorado 80202 Phone: 303-573-1130 Fax: 303-573-1779 American DataBank
University of Michigan COVID-19 Vaccine You must answer the COVID-19 Vaccine question and if you have received your COVID-19 Dose 1 Document
Tracking Package COVID-19 Vaccine, please submit your doses here.
Date

UMID ID

UMICH Email

Manufacturer

Lot Number

COVID-19 Dose 2 Document

Date

UMID ID

UMICH Email

Manufacturer

Lot Number

COVID-19 Single Dose Document

Date

UMID ID

UMICH Email

Manufacturer

Lot Number

110 Sixteenth Street 8th Floor Denver, Colorado 80202 Phone: 303-573-1130 Fax: 303-573-1779 American DataBank