RHODES IMMUNIZATION RECORD

Page 1 of 4
Students and parents; please read the information on Hepatitis B and Meningitis Vaccines. Fill in the dates vaccines
were received or sign the waivers.
Return this form to Rhodes College, Student Health Center
2000 N. Parkway, Memphis, TN 38112
Health-forms@rhodes.edu

Student’s Name ___________________________________D.O.B. _______________ Rhodes ID ______________

The General Assembly of the State of Tennessee mandates that each post-secondary institution in the state provide information concerning
Hepatitis B infection to all students entering the institution for the first time. Those students who will be living in on-campus housing
must also be informed about the risk of meningococcal infection. The required information below includes the risk factors and dangers of
each disease as well as the information on the availability and effectiveness of the respective vaccines for persons who are at-risk for the
diseases. The information concerning these diseases is from the Centers for Disease Control and Prevention and the American College
Health Association.

The TN law requires that all new in-coming students either receive the vaccinations (as outlined below) or sign a waiver
indicating that they do not wish to receive the vaccines.

A. Hepatitis B (HBV) Immunization [TO BE COMPLETED BY ALL NEW IN-COMING STUDENTS - MANDATORY]
Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure,
and even death. The disease is transmitted by blood and/or body fluids and many people will have no symptoms when they develop
the disease. The primary risk factors for Hepatitis B are sexual activity and injection drug use. This disease is completely
preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of
vaccine are required for optimal protection. Missed doses may still be administered to complete the series if only one or two have
been previously received. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.

_____ I hereby certify that I have read this information and I have received the initial dose of the Hepatitis B vaccine. Supply
vaccine information on the health questionnaire.
_____ I hereby certify that I have read this information and I have elected NOT to receive the Hepatitis B vaccine.

Signature of Student (or Parent/Guardian if student is under 18): _________________________Date:

________________________

B. Meningococcal Meningitis Vaccine [TO BE COMPLETED BY ALL NEW INCOMING STUDENTS- MANDATORY]
Meningococcal disease is a rare but potentially fatal bacterial infection, expressed as either meningitis (infection of the membranes
surrounding the brain and spinal cord) or meningococcemia (bacteria in the blood). Meningococcal disease strikes about 3,000
Americans each year and is responsible for about 300 deaths annually. The disease is spread by airborne transmission, primarily by
coughing. The disease can onset very quickly and without warning. Rapid intervention and treatment is required to avoid serious
illness or death. There are 5 subtypes (serogroups) of the bacterium that causes Meningococcal Meningitis. There are two vaccines
available; one stimulates protectice antibodies to serogroup B and another protects against the most common strains of the disease,
serogroups A, C, Y and W-135. The duration of protection is approximately 3 to 5 years for Menomune and even longer for the
conjugate vaccine Menactra. The vaccines are very safe and adverse reactions are almost always mild and local, consisting primarily
of redness and pain at injection site lasting up to two days. The Advisory Committee on Immunization Practices (ACIP) of the U.S.
Centers for Disease Control and Prevention (CDC) recommends that college freshman (particularly those who live in dormitories or
residence halls) be informed about meningococcal disease and the benefits of vaccination and those students who wish to reduce their
risk for meningococcal disease be immunized. Other undergraduate students who wish to reduce their risk for meningococcal
disease may also chose to be vaccinated.
Vaccine for serogroups A, C, Y, and W:
_____ I hereby certify that I have read this information and I have received the vaccine for Meningococcal Meningitis (A, C, Y,
W). Supply vaccine information on the health questionnaire.
_____ I hereby certify that I have read this information and I have elected NOT to receive the vaccine for Meningococcal
Meningitis.
Vaccine for serogroup B:
_____ I hereby certify that I have read this information and I have received the vaccine for Meningococcal Meningitis (B). Supply
vaccine information on the health questionnaire.
_____ I hereby certify that I have read this information and I have elected NOT to receive the vaccine for Meningococcal
Meningitis.

Signature of Student (or Parent/Guardian if student is under 18):

 _________________________Da
te:___________________

For more information about Meningococcal Meningitis and hepatitis B disease and vaccine, please contact your local
health care provider or consult the Centers for Disease Control and Prevention web site at www.cdc.gov.
RHODES IMMUNIZATION RECORD
Page 2 of 4
This form MUST be completed and signed by your physician. All information must be in English.
Return this form to Rhodes College, Student Health Center
2000 N. Parkway, Memphis, TN 38112
Health-forms@rhodes.edu
Student’s Name ___________________________________D.O.B. ______________ Rhodes
I.D._______________

REQUIRED IMMUNIZATIONS DATE AMINISTERED (MM/DD/YR)

1. TETANUS-DIPHTHERIA-PERTUSSIS (required for all students)
dT booster within 10 years……………………………………………… _____-_____-_____
OR OR
Tdap within past 10 years……………………………………………….. _____-_____-_____
2. HEPATITIS B (waiver or vaccination required)
#1_____-_____-_____
Dose #1…………………………………………………………………..
Dose #2 (1-2 mo after 1st)………………………………………………. #2_____-_____-_____
st
Dose #3 (4-6 mo after 1 )……………………………………………….
#3_____-_____-_____
3. M.M.R. (MEASLES, MUPMS, RUBELLA)
(Two doses required at least 28 days apart for students born after 1956)
1. Dose 1 given at age 12 months or later……………………………. #1_____-_____-_____
2. Dose 2 given at least 28 days after first dose……………………….
#2_____-_____-_____
4. MENINGOCOCCAL (waiver or vaccination required) Menactra _____-_____-_____ OR
Should be repeated every 5 years if risk persists (i.e. travel needs)
Menomune _____-_____-_____
Serogroup B _____-_____-_____
5. POLIO (primary series required for all students) □IPV
Date of last dose………………………………………………………… _____-_____-_____ □OPV

6. VARICELLA
History of disease Yes□ No□
If No History of Disease:
1. Varicella Antibody Titer ____-____-____ Result: Positive____Negative____
OR
2. Immunization required if titer negative and no disease history
#1 _____-_____-_____
Dose #1……………………………………………………………
Dose #2 given at least 4 weeks after 1st…………………………. #2 _____-_____-_____

RECMMENDED IMMUNIZATIONS DATE ADMINISTERED (MM/DD/YR)

1. HUMAN PAPILLOMAVIRUS VACCINE (HPV2 or HPV4) #1 _____-_____-_____ □Quadrivalent
(three doses of vaccine for female or male college students 11-26 years of age at 0, 1-
#2 _____-_____-_____ (HPV4) OR
2, and 6 month intervals)
#3 _____-_____-_____ □Bivalent (HPV2)
2. HEPATITIS A (strongly recommended for all students, but not required)
#1 _____-_____-_____
Dose #1…………………………………………………………………
Dose #2 (given 6-12 mo after first)....………………………………… #2 _____-_____-_____
Examining Physician

Name________________________________________Address_____________________________________
_

Signature_____________________________________Phone_______________________________________
_
RHODES IMMUNIZATION RECORD
Page 3 of 4
This form is to be completed by the incoming student or parent. All information must be in English.
Return this form to Rhodes College, Student Health Center
2000 N. Parkway, Memphis, TN 38112
Health-forms@rhodes.edu

Student’s Name ____________________________________________________D.O.B.

______________________

Tuberculosis (TB) Screening Questionnaire:

Please answer the following questions:
Have you ever had a positive TB skin test? Yes ___ No ___
Have you ever had close contact with anyone who was sick with TB? Yes ___ No ___
Have you ever been vaccinated with BCG? Yes ___ No ___
Were you born in one of the countries listed below and arrived in the U.S. within the past 5 years? Yes ___ No ___
(If yes, please CIRCLE the country)
Have you ever traveled** to/in one or more of the countries listed below? Yes ___ No ___
(If yes, please CHECK the country/ies)
Have you been a resident, employee, or volunteer in a high-risk congregate setting? Yes ___ No ___
(correctional facilities, nursing homes, homeless shelters, hospitals, other health care facilities)

Afghanistan Ethiopia Mozambique Tajikistan

Algeria Fiji Myanmar Thailand
Angola Gabon Namibia Timor-Leste
Argentina Gambia Nauru Togo
Armenia Georgia Nepal Tonga
Azerbaijan Ghana Nicaragua Trinidad and Tobago
Bahrain Guatemala Niger Tunisia
Bangladesh Guinea Nigeria Turkey
Belarus Guinea-Bissau Niue Turkmenistan
Belize Guyana Pakistan Tuvalu
Benin Haiti Palau Uganda
Bhutan Honduras Panama Ukraine
Bolivia (Plurinational State of) India Papua new guinea United Republic of Tanzania
Bosnia & Herzegovina Indonesia Paraguay Uruguay
Botswana Iraq (Islamic Republic of) Peru Uzbekistan
Brazil Japan Philippines Vanuatu
Brunei Darussalam Kazakhstan Poland Venezuela(Bolivian Republic of)
Bulgaria Kenya Portugal Viet Nam
Burkina Faso Kiribati Qatar Yemen
Burundi Kuwait Republic of Korea Zambia
Cambodia Kyrgyzstan Republic of Moldova Zimbabwe
Cameroon Lao People’s Democratic Republic Romanian
Cape Verde Latvia Russian Federation
Central African Republic Lesotho Rwanda
Chad Liberia Saint Vincent and the Grenadines
China Libyan Sao Tome & Principe
Colombia Lithuania Senegal
Comoros Madagascar Serbia
Congo Malawi Seychelles
Cote d’Ivoire Malaysia Sierra Leone
Democratic People’s Republic of Korea Maldives Singapore
Democratic Republic of the Congo Mali Solomon Islands
Djibouti Marshall Islands Somalia
Dominican Republic Mauritania South Africa
Ecuador Mauritius South Sudan
 El Salvador Mexico Sri Lanka
Equatorial Guinea Micronesia (Federal State of) Sudan
Eritrea Mongolia Suriname
Estonia Morocco Swaziland
Source: World Health Organization, Global Health Observatory, Tuberculosis Incidence 2009. Countries with incidence rates of ≥ 20 cases
per 100,000 population. For further updates, refer to http://apps.who.int/ghodata/?vid=510

If the answer is YES to any of the above questions, a physician MUST complete page 4 of the Immunization Record.
If you answered NO to all of the above questions, do NOT complete page 4.

Student Signature___________________________________________________________________________________

RHODES IMMUNIZATION RECORD

Page 4 of 4
This form MUST be completed and signed by your physician if you answered YES to any of the questions on page
3. All information must be in English.
Return this form to Rhodes College, Student Health Center
2000 N. Parkway, Memphis, TN 38112
Health-forms@rhodes.edu

Student’s Name__________________________________________________ D.O.B.____________________________

TUBERCULSIS (TB) RISK ASSESSMENT

Persons with any of the risk factors from page 3 of the Immunization Record, are required to have either a TB skin test
(PPD) or Interferon Gamma Release (IGRA). If a previous positive test has been documented, please provide proof of a
current normal chest x-ray or documentation of treatment.

Does the student have signs or symptoms of active tuberculosis disease? Yes _____ No _____
1. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration,
write
“0”. The TST interpretation should be based on mm of induration as well as risk factors.)
Date Given: ____/____/____ Date Read: ____/____/____
M D Y M D Y
Result: ________ mm of induration Interpretation: positive____ negative____
**Interpretation guidelines
>5 mm is positive: >10mm is positive:
· Recent close contact of an individual · Persons born in a high prevalence country or who resided in
with infectious TB one for a significant* amount of time
· Persons with fibrotic changes on a prior chest · History of illicit drug use
x-ray consistent with past TB disease · Mycobacteriology laboratory personnel
· Organ transplant recipients · History of resident, worker or volunteer in high-risk
· Immunosuppressed persons: taking > 15mg/d congregate settings
of prednisone for > 1 month; taking a TNF-a · Persons with the following clinical conditions: silicosis,
antagonist diabetes mellitus, chronic renal failure, leukemias and
· Persons with HIV/AIDS lymphomas, head, neck or lung cancer, low body weight
(>10% below ideal), gastrectomy or intestinal bypass, chronic
malabsorption syndromes

>15mm is positive:
· Persons with no known risk factors for TB disease
2. Interferon Gamma Release Assay (IGRA)
Date Obtained: ____/___/___ (specify method) QFT-G QFT-GIT other_____
M D Y
Result: Negative___ Positive___ Intermediate___

If the results are positive, proceed to 3

 3. Chest x-ray: (Required if TST or IGRA is positive)
Date of chest x-ray: ____/____/____ Result: normal____ abnormal_____
M D Y

Examining Physician

Name ______________________________________ Address _____________________________________________

Signature ____________________________________ Phone _______________________________________________