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UMKC School of Medicine

Instructions: All immunizations below are required. Have your physician complete this form indicating the dates you
have received each vaccine. The physician must sign this form. Simply attaching copies of your immunization record
will not suffice, but we do need titers for varicella/chicken pox. After completion, students must sign and date the
bottom of the form. A parent/guardian signature is required if the student is under 18 years of age. Return to the
Student Affairs office at least one month in advance of your start date.

Student Name: __________________ Date of Birth: _________ Cell Phone #: ____________

Tuberculosis: All students must have had a TB test within 1 year of your start date. In addition, you must have a TB test
performed by the SOM's contracted facility. For UMKC Students, this will be arranged within your first month of school.
For visiting, non UMKC students, this will occur within your first week of your rotation. If you have a positive history of
TB or have tested positive to TST in the past, then submit documentation of your original TB positive results,
documentation of treatment, and your most recent 2-view chest x-ray report (must be performed within the past 1 year).
All students are required to have a TB Test yearly. All students will have two TB Tests within their first year at the School
of Medicine.
TB test result:_______ mm induration Date of test: ________
(mm/dd/yyyy)
Influenza: Current Season Influenza Vaccine (required) Date of Vac: _________
(mm/dd/yyyy)
DPT: Diphtheria, Pertussis, Tetanus. Initial series of 5 and a Tdap booster within 10 years.
First dose: _________
(mm/dd/yyyy)
Second: _________
(mm/dd/yyyy)
Third: _________
(mm/dd/yyyy)
Fourth: __________
(mm/dd/yyyy)
Fifth: _________
(mm/dd/yyyy)
Tdap: _________
(mm/dd/yyyy)
MMR: Measles, Mumps, & Rubella. 2 doses are required; First dose: _________
must be administered at least 1 month apart. (mm/dd/yyyy)
Second: _________
(mm/dd/yyyy)
Chicken Pox: 2 doses are required; must be administered at least 1 month First dose: _________
apart. (mm/dd/yyyy)
If you have had the chicken pox disease, give the month and year AND the date Second: _________
of the positive antibody test, and include titer documentation. (mm/dd/yyyy)
Date of Illness: _________
(mm/yyyy)
Antibody test: _________
(positive) (mm/dd/yyyy)
Hepatitis B: Series of 3 injections (administered at 0, 1 month, 3 months). First dose: _________
Lifetime immunity is established with completion of the series of 3. (mm/dd/yyyy)
Second: _________
(mm/dd/yyyy)
Third: _________
(mm/dd/yyyy)
Meningitis: Recommended for college students. Missouri law requires that all Date of Vac: _________
residence hall students receive shot or sign a waiver stating they have received
(mm/dd/yyyy)
information about the risks with this disease.
Waiver Signed: _________

Form updated 5/2017

I certify all facts provided above are true and complete. I understand false information can result in disciplinary action.

_____________________ ___________
Signature of Student Signature of Parent/Guardian Date
Required if student is under 18 years of age

_______________________________ ___________________
Signature of Physician Date