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HCM 422 5Aug14

HCM 422: Immunizations Record

Recommended Update Effective 7/2009
The following two sections will be honored by HCM 422 students prior to
the start of your internship:
If a student interns at a facility with further health requirements, student will honor
requirements as requested.
K. Immunizations: SIUC and student shall comply with the immunization
requirements of the
facility. Student must have the following immunizations with documentation
available upon request:
1. TB skin test. The test or chest x-ray must be negative.
2. Rubella (German Measles) immunization or positive Rubella Screen or
3. Rubeola (Red Measles) immunization or positive Rubeola Screen or titer
4. Mumps immunization in 1969 or later or physician diagnosed illness. (After
written documentation of immunization of live mumps vaccine at 12 months
of age or

5. MMR (Mumps, Measles, Rubella) immunization. (Two doses of MMR
separated by
more than one mouth and given on or after the first birthday eliminate the
need for 2, 3, 4 above.)

L. Hepatitis B Vaccination: Upon request, SIUC shall submit evidence to facility

that each
student has received Hepatitis B vaccinations or signed a waiver
registering they are
aware of the risks without vaccinations.

In the MOU, the SIUC Immunization Compliance Form requires by law reads:
The required immunizations on file at Student Health Services are as follows (DO
NOT FILL IN-on file already if on campus;
If student off campus site, MUST COMPLETE and submit to Internship Coordinator):


Dose 1 ___________
Dose 2
Dose 3
Booster Dose __________ (within last 10 years)
MMR (Measles, Mumps, Rubella)
Dose 1 ___________
Dose 2
Dose 1 ___________
Dose 2
Date disease diagnosed and certified by physician
Lab test proving immunity (attach lab report)
Dose 1

Or Lab test proving immunity ____________________



Dose 1 ___________
Date disease diagnosed and certified by physician ____________
Lab test proving immunity (attach lab report)

The following immunizations are optional for attendance at SIUC but I would
highly recommend and/or are required for HCM internship students to
receive the following due to possible exposure at your sites (*TB skin test-(required), **Hepatitis B, and ***flu vaccine{some facilities}). Students
interning at nursing homes, assistant living facilities or those working directly with
patients should seriously consider the following immunizations for your residents
safety and your safety:

Tuberculosis Skin Test

Hepatitis B

Flu Vaccine

Tdap Vaccine

2dnd Mumps Vaccine

Date: ___________________ Results of skin test ______mm

Or Quanti-FERON TB-Gold
Dose 1 _______________
Dose 2 _______________
Dose 3 _______________
Dose _______________
Dose 1 _______________
Date of Disease ______________
Or Blood Titer ______________
Dose 1 ______________
Dose 2 ______________
Dose 3 ______________
Dose ______________
Dose _______________

Note: (*TB skin test REQUIRED

**Hepatitis B Signed waiver if not received
***Flu vaccinerecommended)
Therefore, please make certain that immunizations listed in K and L are
completed and on file at the Health Services (on campus students) or on
file with Internship Coordinator (off-campus students).
Also, please download this attachment, sign and send/drop off to Dr. Beebe
stating you are in compliance with immunizations requested in MOU or in the
process of completing those immunizations/vaccines when available.
______________________________Raven Pearson 01/21/2015_____________


If you have any questions about the recommended immunizations, you may
contact the Student Health Services, 618 453-3311. Any questions regarding MOU
internships, please contact Dr. Beebe
(618 453-7202, 618 534-6470 or
Thank you,
Dr. S. N. Beebe
Health Care Management Internship Coordinator

SAH, ASA, MC 6615

Southern Illinois University Carbondale
Carbondale, IL 62901
618 534-6470 cell
618 453-7202 off
618 453-7020 Fax
snb 5Aug14