Application Checklist To avoid delays in processing application please - PDF document

1 Application Checklist To avoid delays in
Application Checklist To avoid delays in processing application, please send in all items at the same time. signature of Dean or Certifying Officer and school seal is affixed. Check payable to University of Washington for non-refundable application fee of $100 per department is enclosed. The Student’s school has verified validity of their malpractice/liability insurance with a minimum or $1 million per occurrence and that this coverage will be valid during the dates of the requested clerkship. A copy of the current policy is enclosed. If policy expires prior to rotation, a letter stating that the policy will be renewed is enclosed. The student has received a Pass on the USMLE Step 1 or COMLEX Level 1. Copy of Health Insurance Card is included in application. Student has completed a documented training program in universal precautions ensuring the appropriate handling of blood, tissues, and body fluids during the time of his/her M.O. or D.O. training. UW SOM Immunization / Health Verifilete by having dates filled in and signed by a health care official. send in personal immunization records. UW SOM Essential Requirements of Medical Education form is signed and dated. UW Medicine Privacy, Confidentiality, and Information Security Agreement form is signed and dated. Signed and dated Consent and Self Disclosure Statement downloadable from the Verified Credentials website ls.com/washington/default.cfmVerified Credentials National Background check (this background check will include: Criminal Search – County, National CriminalDatabase, National Sex Offender Public Registry, and Washington State Patrol – WATCH) and is current within the last two years.Send copy of the report with application. https://client.verifiedcredentials.com/washington/default.cfmVA HIPAA training certificates for both Information Security Awareness and Privacy Policy are included with application.https://www.ees-learning.netIf school did not verify BLS certification on this application, enclose copy of current card. We do not accept ACLS cards as aIf HIPAA training has already been complee HIPAA Training Certification form. Digital photo has been emailed to visitstu@uw.edu in JPG format.Please contact us if you have any questions. If you have not already completed HIPAA training, a UW HIPAA log-in ID will be requested. This can take anywhere from 3-10 days to receive. You will be emailed the log-in ID and instructions. Once all the above items have been received and HIPAA training completed, your application will be forwarded to the department(s). All correspondence henceforth should be directed to the department. Completed application with above items must be returned to: Visiting Student Program, Academic Affairs, School of Medicine, University of Washington, 1959 NE Pacific Street, Suite A300, Box 356340, Seattle, WA 98195-6340. DO NOT RETURN TO DEPARTMENT. Fax: 206-543-9052 SCHOOL SEAL UNIVERSITY OF WASHINGTON, SCHOOL OF MEDICINE APPLICATION FOR CLINICAL ELECTIVE 2012-2013STUDENT DATA SHEET Visiting D.O. Student or Canadian Medical Student To be completed by student. (Please print clearly or type) Gender (circle): F M LAST FIRST M.I. STREET CITY/STATE/ZIP CODE Phone: ( _ _ _ ) _ _ _ - _ _ _ _ E-mail: ____________________________________________________________________________ SSN #______-_____-______Birthdate: _ _ / _ _ / _ _ Birth Place ____________________________________________ US Citizen? CITY/STATE/ COUNTRY

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1 2 3 I certify that my personal health insurance is in effect through the end date of requested elective (please provide copy of insurance card): M.D. D.O. degree in his/her third fourth year #weeks___Ob/Gyn #weeks___ Pediatrics _ #weeks___ Surgery #weeks___ Psychiatry _ #weeks___; Family Medicine _ _ #weeks___ The student has received a Pass on the USMLE Step 1 or COMLEX Level 1.The student is covered with a minimum of $1 million per occurrence in malpractice/liability insurance while away from his/her degree-granting institution. En SIGNATURE OF SCHOOL OFFICIAL DATE PRINT NAME OF SCHOOL OFFICIAL TITLE (continued on next page…) NAME OF MEDICAL SCHOOL TELEPHONE/FAX # MAILING ADDRESS CITY/STATE/ZIP CODE 3 of 3 pages employers or household members. UW Medicine must obtain satisfactory assurances (data use agreements) from the entity requesting a limited data set prior to allowing the use or disclosure. PHI may be de-identified through removal of 18 specific identifiers. Once de-identified, the data is no longer subject to state or federal privacy laws and regulations. When using or disclosing PHI for payment and health care operations or when the patient has not authorized the use or disclosure, providers may only disclose the minimum necessary PHI required to accomplish the intended purpose. UW Medicine provides all patients (except prisoner patients) a copy of its Notice of Privacy Practices (NPP), which outlines how an individual’s PHI will be used or disclosed. UW Medicine is required to make a good faith effort to obtain written acknowledgement of receipt of the NPP from each patient treated. . Individuals treated at UW Medicine facilities have a right to request additional restrictions on the use or disclosure of their PHI. UW Medicine is not required to agree to any restriction. If UW Medicine does agree then it must follow the agreed-upon restrictions. All agreed-upon restrictions must be documented in the individual’s designated record set. The designated record set contains an individual’s medical and billing records, and other information used to make decisions about the individual. An individual has the right to access, inspect or request a copy of PHI contained in the UW Medicine designated record set, unless an exemption applies (e.g., psychotherapy notes, information compiled for risk management purposes, etc.). Requests to access, inspect or photocopy PHI should be referred to the Release of Information Service Area for the entity in which services are provided. An individual may ask a health care provider to correct or amend his or her health care record. Requests must be in writing and state a reason for the requested change. UW Medicine has ten days from receipt of the request to respond in writing. If a provider receives a request for amendment, he or she must immediately contact the Release of Information Service Area for the entity in

3 which services are provided. An i
which services are provided. An individual has the right to request UW Medicine to provide an accounting of all disclosures from an individual’s designated record set, excluding those uses or disclosures for which an accounting is not required (e.g., treatment, payment, or health care operations; uses or disclosures made with the individual’s authorization; or uses or disclosures incidental to an authorized use or disclosure). If you receive a request for an accounting, please contact the entity’s Health Information Management Area. Defines the UW Medicine Medical Record Designated Record Set and the Billing Designated Record Set. This policy sets forth the framework for UW Medicine’s collection, management and use of SSNs and is applicable to all UW Medicine units. SSNs must be appropriately encrypted according to UW Medicine Information Security Policy SEC-05.03 – Encryption Standard. To protect patient privacy and to decrease the risk of a breach of confidentiality, patient information should only be faxed to fulfill a treatment, payment, or health care operation obligation or a specifically authorized request. If I have any questions or would like to know more about these policies and procedures, I can contact a Privacy Officer or view the materials at http://depts.washington.edu/comply/privacy.shtml Dated _____________________ ____________________________________ Signature ___________________________________ Print Name ____________________________________ Department and Box No. Documentation to me maintained in workforce member department record 2 of 3 pages non-UW Medicine entities for payment purposes. Questions regarding the sharing of PHI for the health care operations of a non-UW Medicine entity should be directed to the Privacy Official of the entthe patient. Any other disclosure of PHI requires a valid authorization, unless the disclosure is allowed by PP16. Health care providers may communicate face-to-face with their patients about health related products or services that UW Medicine provides. Providers may also communicate with their patients about alternative treatments, coordination of care, or specialty care. UW Medicine must obtain the patient’s authorization for any use or disclosure of PHI for non face-to-face marketing unless it is a promotional gift of nominal value. UW Medicine may use or disclose patient demographic information and the dates when patients received health care services to raise funds for its own benefit. UW Medicine must obtain an authorization for the use or disclosure of any other PHI for fundraising purposes. Individuals have the right to opt out of fundraising communications. UW Medicine has identified staff within UW Medicine who will respond to requests for disclosure of PHI. UW Medicine will verify the identity of all requestors and the requestors’ legal authority for obtaining PHI. UW Medicine will document the requestors’ authority to receive the PHI prior to release of PHI. UW Medicine may disclose PHI to a business associate that is performing an activity on its behalf when UW Medicine obtains satisfactory assurances that the business associate will safeguard the information. Satisfactory assurances are documented in writing through a business associate agreement. Relationships between health care providers involving the treatment of a patient do not require satisfactory assurances and are therefore not business associate relationships. Please contact your entity’s Privacy Official if you have questions about whether a business associate relationship exists in a specific situation. Upon admission, patients have the opportunity to decide whether to be included in the hospital’s inpatient directories. If a patient opts against disclosure in the directory, UW Medicine will no

4 t include that patient in the directory.
t include that patient in the directory. If a patient is incapacitated at admission, the provider should exercise his or her best judgment on he patient is able to express an opinion. Hospitals may release the condition and location of patients when a requestor asks for the patient by name. With the permission of the patient, clergy of the same faith may be given directory information without asking for a patient by name. With exceptions, the personal representative or legally authorized surrogate decision-maker for the patient may sign the acknowledgement for receipt of the UW Medicine Notice of Privacy Practices (Notice) and make decisions concerning UW Medicine's use and disclosure of the individual or emancipated minor’s PHI. In addition, unemancipated minors may sometimes acknowledge receipt of the UW Medicine and make decisions concerning UW Medicine's use and disclosure of their PHI. UW Medicine may use or disclose PHI to relatives or other persons involved in the treatment or care of the patient, provided the patient does not object. When a patient is unable to express his or her wishes, the provider should exercise professional judgment on whether to release any PHI. If PHI is disclosed under these circumstances, UW Medicine will let the patient know of the disclosure as soon as possible. UW Medicine may use or disclose PHI without an individual’s authorization for public health activities, health oversight activities, and specialized government functions. UW Medicine may also use or disclose PHI without an individual’s authorization to avert a serious threat to the health or safeenforcement when required to do so by law, or pursuant to legal process. Please contact the Privacy Official for your entity for fact-specific questions. Psychotherapy notes maintained by behavioral health providers are a subset of PHI subject to heightened confidentiality protections. Psychotherapy notes may be used or disclosed absent the patient’s authorization to conduct UW Medicine training programs, for treatment by the behavioral health professional, to defend against legal action, to protect the health or safetyen required by law. Research involving human subjects requires review by an approved Institutional Review Board (IRB). Researchers may use or disclose PHI for research when authorized by the human subject or pursuant to an IRB-approved waiver of authorization or alteration. For more information on conducting research, please review the UW Human Subjects Division web page at http://www.washington.edu/research/hsd/index.php. Federal law allows UW Medicine to use or disclose a limited data set for research, public health, or health care operations. A limited data set is PHI that excludes 16 specific identifiers of the individual or of relatives, PP-04 Attachment C Rev. 5/8/2008 HIPAA TRAINING CERTIFICATION I, certify that I have received training (Print Name) on the confidentiality of patient health information, specifically the privacy regulations adopted pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), at on / / . Name and location of facility) (Day/month/year) http://depts.washington.edu/comply/privacy.shtml . Additionally I understand and have reviewedand received a copy of the following summary of selected UW Medicine Privacy Policy and Procedures: The University of Washington (UW) is a hybrid entity with both health care components and non-health care Prior to April 14, 2003, and until the individual's first contact with UW Medicine for services, UW Medicine entities may continue to rely on the individual's “Registration Consent /Financial Agreement,” authorization, or other express legal permission to use and disclose PHI for treatment, payment, or health car

5 e operations. Each UW Medicine entity wi
e operations. Each UW Medicine entity will obtain the individual’s acknowledgement of receipt of the UW Medicine Notice of Privacy Practices or make a good faith effort to obtain an acknowledgment for all services provided after April 14, 2003. PP-03. The law requires UW Medicine to train its workforce, including physicians, on the organization’s policies and procedures. UW Medicine maintains documentation of the training provided to each individual for six years. Patients and their families have the right to file complaints about how UW Medicine and individual health care providers use or disclose their PHI. They may complain to the UW Medicine Privacy Office, the individual UW Medicine entity, or the U.S. Department of Health and Human Services • Office for Civil Rights (OCR). If any person complains to a member of the UW Medicine Workforce about a use or disclosure of PHI, the workforce member must contact the Privacy Official of the entity rendering the care immediately. UW Medicine will not retaliate, or tolerate retaliation, against any one who files a complaint. UW Medicine may share PHI for treatment, payment or health care operations among the UW Medicine entities and with UW components that support UW Medicine. UW Medicine may share PHI with any non-UW Medicine health care provider for treatment purposes. UW Medicine may share the minimum necessary PHI with The following table is a glossary of terms used in the Privacy, Confidentiality, and Information Security Agreement. Term Definition Access To use, change, or view information. Authorized duties or activities Duties or activities that are established by those with appropriate authority related to the role or function of the workforce member, like a supervisor, manager or director. Authorized software Software that is authorized for use by the designated System Owner or Department Manager CONFIDENTIAL CONFIDENTIAL Informationinformation that is very sensitive in nature, and requires careful controls and ion could seriously and adversely impact UW Medicine or interests of patients, other individuals, and organizations associated with UW Medicine. Examples include: personally identifiable information, protected health information, workforce records, student records, social security numbers, legally protected University records, research data, passwords, intellectual property. Confidentiality Expectation that information will be prot Disclose Release, transfer, provision of access to, or divulg Individually identifiable patient Individually identifiable health information is information that is a subset of patient information, including demographic information collected from an individual, and: That identifies the individual; or With respect to which there is a reasonable basis to believe the information can be used to identify the individual. and (1) Is created or received by a health care provider (2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. Licensed software Software that the University of Washington has been grlicense agreement or contract. necessary Minimum Necessary Standard: When using or disclosing Protected Health Information, UW Medicine must make reasonable efforts to limit PHI to the minimum necessary to accomplish the intended purpose of the use, disclosure or request. The minimum necessary standard does not apply to Disclosures to or requested by a health care provider for treatment purposes To the patient or pursuant to an authorization Uses and/or Disclosures required by law Uses or disclosures that are required for co Orally disclosed Spoken words either in person or over any communication device. Protected Health Info

6 rmation (PHI) information is a subset o
rmation (PHI) information is a subset of individually identifiable health information maintained in permanent health records and/or other clinical documentation Privacy Official Each entity within UW Medicine has designated a Privacy Official who assists the UW Privacy Officer in developing and implementing UW Medicine’s policies and procedures. The entity Privacy appoint designee(s) to assist in the performance of these functions. Proprietary UW Medicine possesses exclusive rights over the information within its systems. This includes business plans, intellectual property, financial information or other sensitive materials and information in printed, electronic or oyee rights or organization’s operations. RESTRICTED RESTRICTED Information is information that is business data, which is intended strictly for use by designated UW Medicine employees and agents. This classification applies to information less sensitive than CONFIDENTIAL information. Dissemination of this information shall only be made to UW Medicine workforce with an established need-to-know. Safeguard using precautionary measures. Workforce Faculty, employees, trainees, volunteers, and other persons who perform work for UW Medicine, and whose work conduct is under UW Medicine’s direct control regardless of whether or not the workforce member is paid by UW UW Medicine UW Medicine includes the following entities: University of Washington Medical Center and Clinics; Harborview Medical Center and Clinics; UW Medicine Neighborhood Clinics (University of WashiUW Physicians Sports Medicine Clinic; Hall Health Primary Care Center; University of Washington Physicians; as well as certain services and activities that support UW Medicine that are performed by non-healthcare components of the University of Washington as defined within Privacy Policy PP-01 Use & Disclosure of Protected Health Information – Organizational RequiremWashington Health Care Components are subject to the UW Medicine Information Security Program. PP-04 Attachment A Rev. 10/23/06 Privacy, Confidentiality, and Information Security Agreement As a user of UW & UW Medicine computing resources and data, I understand that I am responsible for the security of my User ID (login) (s) and Password(s) to any UW and/or UW Medicine computer system for which I am granted access. I understand that it is my responsibility to protect my password’s confidentiality. I understand that I have the following responsibilities: Support compliance with federal and state statutory and Protect access accounts, privileges, and associated passwords (examples: Not sharing my password and Not logging on for Maintain the confidentiality of information to which I am given access privileges; Accept accountability for all activities associated with the use of my individual user accounts and related access privileges; Not to change the computer configuration unless specifically Not to download, install or run unlicensed or unauthorized Use only licensed and authorized software; Ensure that my use of UW & UW Medicine computers, email, stored, or used on any of these systems is restricted to authorized duties or activities; If I have clinical systems access, I may access my own PHI; Workforce members may not access the records of their family members, including minor children, nor any other person if not an assigned or job-related duty. This also applies in cases where staff members hold authorizations or other legal authority Report all suspected security and/or policy violations to my Help ns to the appropriate entity’s Privacy Official or the UW Medicine Privacy Office I understand that where I have access to or use of information classified as RESTRICTED or CONFIDENTIAL, additional protections are expected. Proprietary information, which includes business

7 plans, intellectual property, financial
plans, intellectual property, financial information or other sensitive materials and information in printed, electronic or verbal form that may affect workforce member’s rights or organizational operations, is an example of a Ron, which includes individually identifying patient information in any form, sensitive student information, and ENTIAL information collected or obtained from, analyzed, or entered into any UW Minformation management system(s) or database(s) is the property of UW Medicine unless otherwise specified by contract. I undermaintain and safeguard the confidentiality of any and all UW Medici information accessed or obthe performance of my authorized duties or activities. I will not access, use, and/or disclose RESTRICTED and/or CONFIDENTIAL any purpose other than the performance of authorized activities or duties. I will limit my access, use and disclosure to the information necessary to perform my authorized activity or duty. I will safeguard all RESTRICTED and/ have RESTRICTED and/or CONFIDENTIAL information may be monitored to assure appropriaccess and compliance with system integrity. I understand that authorized use carries with it the responsibility to follow the UW Medicine Privacy and Information Security policies that govern the use of RESTRICTED and/or CONFIDENTIAL information, computers, and networks. I understand that failure to comply with the above Privacy, Confidentiality, and Information Security agreement may result in disciplinary action up to and including denial of access to information and termination of my employment at the University to Washington. I have been gi http://depts.washington.edu/comply/privacy.shtml http://depts.washington.edu/comply/security.shtml By signing this Agreement, I understand and agree to abide by the conditions imposed above. Print Name: Department: Job Title: Date: Copy provided on ________________ by Date Name supervisor, manager or designee Signature Provide copy of this Agreement to the workforce member File original Agreement in departmental personnel or academic file. (All signed Agreements must be maintained for 6 years) University of Washington Essential Requirements of Medical Education School of Medicine Admission, Retention and Graduation StandardsThe MD degree is recognized as a broad undifferentiated degree requiring the acquisition of general knowledge and basic skills in all fields of medicine. The education of a physician requires assimilation of knowledge, acquisition of skills and development of judgment through patient care experience in preparation for independent and appropriate decisions required in practice. The current practice of medicine emphasizes collaboration among physicians, allied health care professionals, and the patient. The University of Washington School of Medicine endeavors to select applicants who have the ability to become highly competent physicians. As an accredited medical school, the University of Washington School of Medicine adheres to the guidelines promulgaby the Liaison Committee on Medical Education in "Functions and Structure of a Medical School." Within these guidelines, the University of Washington School of Medicine has the freedom and ultimate responsibility for the selection of students, the desiimplementation, evaluation of its curriculum, evaluation of students, and the determination of who should be awarded a degree. Admission and retention decisions are based not only on prior satisfactory academic achievement but also on non-academic factorwhich serve to insure that the candidate can complete the essential functions of the academic program required for graduation. The School has the responsibility to the public to assure that its graduates can become fully competent physicians, capable of fulfilling the Hippocratic duty

8 to benefit and do no harm. Thus, it is
to benefit and do no harm. Thus, it is important that persons admitted possess the intelligence, integrity, compassion, humanitarian concern, and physical and emotional capacity necessary medicine. The School of Medicine, as part of the University of Washington, is committed to the principle of equal opportunity. The School does not discriminate on the basis of race, color, creed, religion, national origin, gender, sexual orientation, age, marital status, disability, disabled veteran or Vietnam era veteran status. When requested, the University will provide reasonable accommodation to otherwiqualified students with disabilities. PROGRAM Technical standards as distinguished from academic standards refer to those physical, cognitive and behavioral abilities required for satisfactory completion of all aspects of the curriculum and the development of professional attributes required by the faculty of all students at graduation. The essential abilities required by the curriculum are in the following areas: motor, sensory, communication, intellectual (conceptual, integrative, and quantitative abilities for problem solving and diagnosis,) and the behavioral and social aspects of the performance of a physician. The University of Washington School of Medicine curriculum requires essential abilities in information acquisition. The student must have the ability to master information presented in course work in the form of lectures, written material, and projected imagesThe student must have the cognitive abilities necessary to master relevant content in basic science and clinical courses at a level deemed appropriate by the faculty. These skills may be described as the ability to comprehend, memorize, analyze and synthesizematerial. He/she must be able to discern and comprehend dimensional and spatial relationships of structures, and be able to develop reasoning and decision making skills appropriate to the practice of medicine. The student must have the ability to take a medical history and perform a physical examination. Such tasks require the ability communicate with the patient. The student must also be capable of perceiving the signs of disease as manifested through the phyexamination. Such information is derived from images of the body surfaces, palpable changes in various organs, and auditory information (patient voice, heart tones, bowel and lung sounds.) The student must have the ability to discern skin, subcutaneous masses, muscles, joints, lymph nodes, and intra-abdominal organs (for example, liver and spleen.) The student must be able to perceive the presence or absence of densities in the chest and masses in the abdomen. The student must be able to communicate effectively with patients and family, physicians and other members of the health care team. The communication skills require the ability to assess all information including the recognition of the significance of non-verbal responses and immediate assessment of information provided to allow for appropriate, well-focused follow-up inquiry. The student must be capable of responsive, empathetic listening to establish rapport in a way that promotes openness on ity to potential cultural diffeThe student must be able to process and communicate information on the patient's status with accuracy in a timely manner to physician colleagues and other members of the health care team. This information then needs to be communicated in a succinct yet comprehensive manner and in settings in which time available is limited. Written or dictated patient assessments, prescriptions, etc., must be complete and accurate. The appropriate communication may also rely on the student's ability to make a upervision and consultation in a timely manner. The student must be able to understand the basis and content of medical ethics. He/she must possess attributes which include compassion, empathy, altruism, integrity, responsibility and tol

9 erance. He/she must have the emotional s
erance. He/she must have the emotional stability to function effectively under stress and to adapt to an environment which may change rapidly without warning and/or in unpredictable ways. These essential functions of medical education identify the requirements for admission, retention and graduation of applicants at the University of Washington School of Medicine. Graduates are expected to be qualified to enter the field of medicine. It is the responsibility of the student with disabilities to request those accommodations that he/she feels are reasonable and are needed to execute the essential requirements I verify that I have read and understood, and am able to meet with or without reasonable accommodation the Essential Requirements of Medical Education. Signature required for consideration. _ STUDENT’S SIGNATURE DATE TETANUS-DIPHTHERIA-PERTUSSIS Primary childhood series with DTaP or DTP a booster with Tdap meets the requirement. If there is a contraindication to receiving Tdap then this must be documented by a provider and Td must have been received within the last 10 years. Were childhood immunization series completed? NO If YES, is this information by: VERBAL REPORT (records NOT reviewed) DOCUMENTED RECORDS (childhood records reviewed) a booster with Tdap, which became available in the U.S. in June 2005 (Note: Td is a different vaccine, and does not substitute for Tdap): Tetanus-Diphtheria-accelular Pertussis (Tdap) Date: / / _ Official’s initials: ______________ Mo Day Yr Td received, medical contraindication to Tdap. Date: _____/______/_______ (Letter of explanation from provider must be attached Mo Day Yr TWO doses of varicella-containing vaccine given on or after 12 months of age and at least one month apart, or positive Varicella antibody Immunization Dose #1 / / Dose #2 / / given at least one month after Mo Day Yr Mo Day Yr first dose (for all age groups) Positive Varicella antibody titer: / / Official’s initials: Mo Day Yr TUBERCULOSIS SCREENING In addition to a current TB skin test ( PPD) within the last month , another is required within the last year ; otherwise a 2 step test must be done. History of BCG is without documentation of a positive TB test should be tested unless they can show documentation of having completed prophylactic treatment. Chest X-Rays are NOT accepted as substitutions for TB testing. A single IGRA (interferon gamma release assay) blood test result from the last 6 months may be submitted as a substitu#1 Placed: / / Date Read: / / Result: ____________mm Official’s initials: Mo Day Yr Mo Day Yr #2 Placed: / / Date Read: / / Result: ____________mm Official’s initials: DayDay IGRA / / IGRA Positive (CXR required if Mo Day Yr If positive PPD or IGRA, chest x-ray w/in last year is required (older CXR okay if prophylactic treatment has been completed) CXR result: Normal Abnormal Date of CXR: / / (Please attach a copy of the chest x-ray report to this form. Do not send actual films) Mo Day Yr Pr

10 ophylactic treatment (Rx/Dose/Dates/Dur
ophylactic treatment (Rx/Dose/Dates/Duration): ___________________________________________________________________________________ ________________________________________________________________________________________ Official’s initials: _______________ Influenza Vaccine: One dose of Seasonal Flu vaccine required annually. Vaccine: HC provider Mo Day Yr HEALTH CARE PROVIDER or SCHOOL OFFICIAL INFORMATION NOTE: This section must be completed by HCP or School Official for authentication HCP or School Official’s Name ________________________________Title________________________________________ Name of School ________________________________________________________________________________________ Address _______________________________________________________________________________________________ _______________________________________________________________________________________________________ Phone # (_____)________________________ Email ________________________________________________________ I certify the accuracy of the immunization and Disease history detailed above on this form ___________________________________________ ________________ HCP or School Official’s Signature Date DO NOT SEND IMMUNIZATION RECO R DS PLEASE TURN OVER AND CONTINUE COMPLETING OTHER SIDE OF FORM 02/07/2012 REQUIRED IMMUNIZATIONS FOR VISITING STUDENTS UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINEStudent Name: ________________________________________________________________________________________________ Last First Date of Birth (Month/Day/Yr) DOCUMENTATION OF IMMUNIZATION REQUIREMENTS (To be completed by Health Care Provider (HCP) or School Official ONLY) (RUBEOLA):TWO doses of measles-containing vaccine (regardless of birthdate), or a positive antibody titer. The doses must be on or after age 12 months, at least one month apart, and a live virus vaccine after 01/01/68, given without Immune Globulin. #1 / / AND #2 / / Positive titer (serology antibody): / / Mo Day Yr Mo Day Yr Mo Day Yr Please indicate type: Please indicate type: If two MMRs were not documented in #1, please complete the following: MUMPS TWO doses of mumps-containing vaccine (regardless of birthdate) or a positive antibody titer. The doses must have been received on or after the age of 12 months and at least one month apart. Mumps alone must have been live virus vaccine received after 01/01/80. #2 / / Positive titer: / / Mo Day Yr Mo Day Yr Mo Day Yr (GERMAN MEASLES): dose of rubella-containing vaccine on or after 12 months of age or a positive antibody titer. / / Positive titer: / / Official’s initials: Mo Day Yr Mo Day Yr THREE doses of vaccine a positive Hepatitis B surface antibody meets the requirement. Dose #1 / / Dose #2 / / Dose #3 / / Mo Day Yr Mo Day Yr Mo Day Yr Please indicate type: Please indicate type: Please indicate type: Hepatitis B Please indicate type: Please indicate type:Please indicate type: Hepatitis B Hepatitis A/B combined Hepatitis A/B combinedHepatitis A/B combined AND Positive Hepatitis B surface antibody (anti-HBs) titer _ ___ Int’l Units Official’s initials: Mo Day Yr If you are Hepatitis B surface antigen positive or are a carrier – we require additional lab tests. If you are core antibody positive please provide lab report. Information for HCPs or School Officials completing this form: Documentation of immunity to each of the following diseases is REQUIRED initial each section you are authenticating. Your signature and credentials are requested at the end of this form. DO NOT SEND IMMUNIZATIO