Cerritos College

CERRITOS COLLEGE - HEALTH OCCUPATIONS DIVISION

DENTAL HYGIENE DEPARTMENT

IMMUNIZATION / PROOF OF IMMUNITY FORM

Student's name ______________________________________________________________________________

As a part of the physical examination or documented history, the above person has the following.  Please make sure the medical doctor signs at each space where indicated.

1.   TB Clearance:  Skin test must be repeated every 6 months.  If skin test is positive, a chest x-ray must be completed. Please attach documentation of positive skin test and negative chest x-ray.  Chest x-rays must be repeated every two years.

     Type of test _________________________________________________________________________

     Date completed _______________________________________________________________________

     Results:  Positive _______________________________ Negative _______________________________

     Signature of Medical Doctor _____________________________________________________________

2.  Last Tetanus-diphtheria immunization (must be repeated every 10 years):

     Date completed _______________________________________________________________________

     Signature of Medical Doctor _____________________________________________________________

3.  Immunity:  PROOF OF IMMUNITY MUST BE PROVIDED BY TITER.  CLINICAL LABORATORY REPORTS  WITH FACILITY STAMP & MEDICAL DOCTOR'S SIGNATURE ARE REQUIRED FOR THE FOLLOWING:

     A.  Hepatitis B (presence of anti-HBc or anti-HBs):

     B.  Rubeola

     C.  Mumps

     D.  Rubella

     E.  Varicella

     Note: If any titer shows a negative response, appropriate immunizations are required and                     FOLLOW-UP TITERS MUST BE COMPLETED and submitted to the Dental Hygiene Department.

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