Student Health Services
30 Bee Street – Suite 102
Charleston, SC 29425
Telephone 843-792-3664
Fax 843-792-2318
MUSC Student Pre-Matriculation Requirements
Instructions for Completion of Form
All MUSC students, including full-time, part-time, distance, current employees, or returning former students, are required to
submit the following information. The Mandatory Immunization Requirements Form and supporting documentation must be
completed and received by Student Health Services before students will be allowed to attend classes. Maintaining these high
standards is done to protect the safety of the students, staff, and patients.
1.
Measles, Mumps, Rubella – proof of age-appropriate immunization OR immune antibody titers.
Immunization requirements can be met by providing documentation of 2 MMR vaccines received on/after age of 12 months,
and both after 12/31/1967. Students born before 12/31/1956 can submit documentation of one MMR dose given after
12/31/1967. OR
Immune Antibody Titers - Copy of lab report demonstrating immune antibody titers (IgG) to Measles, Mumps, and Rubella. Lab
report should be quantitative and/or specify if test results are in immune range.
2.
Varicella (Chicken Pox) Immunity
•
Documentation of two Varicella vaccines
OR
•
Copy of lab report demonstrating immune antibody titers (IgG) to Varicella. Lab report should be quantitative and/or
specify if test results are in immune range.
3.
Tetanus-diphtheria-acellular pertussis (Tdap) – students are to have completed the childhood DPT series within current CDC
guidelines and provide documentation of having received an adult Tdap booster on or after 5/3/2005. Once adult Tdap booster
has been received, students may resume regular Td boosters every 10 years. Students with a documented allergic reaction to the
pertussis vaccine need to provide a letter from their medical provider detailing the nature of their reaction and the
contraindication to receiving the vaccine.
4.
Meningitis Vaccine (A,C,W,Y) – initial or booster dose must be on or after 16th birthday. Documentation of vaccine or
signed waiver is required .
5.
Hepatitis B Vaccination – is required for students who may have exposure to blood or human body fluids during their
academic coursework. Unvaccinated students should initiate the hepatitis B vaccine series prior to or during their first semester
at MUSC. Previously immunized students must provide proof of the primary hepatitis B series (3 vaccines) AND a Quantitative
Hepatitis B surface Antibody titer (preferably drawn 4-8 weeks after the final dose). Lab report should specify if test results are
in the desired immune range (≥ 10 mIU/mL). If the hepatitis B titer is non-immune (negative or equivocal) immediately after
completion of the primary vaccine series, then complete a second hepatitis B series followed by a repeat titer. Individuals who
failed to develop immunity after their primary hepatitis vaccine series should consider receiving the newer Heplisav-B vaccine
series (2 vaccines given one month apart), which contains a novel adjuvant which stimulates a stronger immune response
compared to the standard recombinant hepatitis B vaccines (Engerix-B, Recombivax HB). Heplisav-B vaccination stimulated
sero-protective antibody levels in 95.4% of recipients versus 81.3% sero-protective antibody levels in those who received the
standard recombinant hepatitis B vaccine. Many who completed their primary hepatitis B series during infancy will have a
negative hepatitis antibody titer when first tested as an adult, often due to waning antibody levels over time. In this population,
it is acceptable to receive a fourth hepatitis B vaccine “booster” followed by a hepatitis antibody titer 4-6 weeks later. If this
hepatitis B titer is immune (≥ 10 mIU/mL), then no further hepatitis vaccines are needed. If the titer is negative, then the
second vaccine series should be completed, followed by a hepatitis B antibody titer. If the hepatitis B antibody titer is negative
after 2 completed hepatitis B vaccine series, then testing for chronic hepatitis B infection is required (Hepatitis B surface
Antigen and Hepatitis B core Antibody).
6.
COVID-19 Vaccination - COVID vaccination is not required for a student to be admitted to MUSC. At this time we have returned
to normal operations.
7.
TB Screening - TB screening tests (TB Skin Test or Blood Assay) are required of all students regardless of prior BCG vaccination.
• TB Blood Assays (QuantiFERON-TB Gold® or T-SPOT®) are the preferred screening tests for most persons (more accurate screening
method, requires a single visit for blood collection, less $ than 2 TB Skin Tests, unaffected by previous BCG vaccination, covered by most
insurance plans).
• TB Skin Testing is an acceptable alternative, though has some drawbacks, including more prone to errors in placement and interpretation,
requires 4 trips to complete 2-step testing (which is often less cost effective than a single TB Blood Assay). Do not have a TB skin test
placed within 28 days of receiving a live vaccine (MMR or Varicella) – this can give a false negative result.
Previous history of previous positive TB skin testing (≥ 10 mm induration) or (+) TB Blood Assay must be accompanied by
documentation of the evaluation and treatment of this condition.
A. Negative Baseline Tuberculosis Screening Tests – persons with negative TB testing need one of the following:
• Blood Assay for Tuberculosis (Interferon Gamma Release Assay/IGRA) within 3 months of enrollment: QuantiFERON-TB Gold® or T-
SPOT®
• Two (2) tuberculosis skin tests (Mantoux 5 TU Tuberculin Skin Tests) administered 1 – 3 weeks apart, and both within 3 months of
enrollment.
• History of recent TB Skin Testing – persons who have had previous TB skin testing within 12 months of enrollment can submit
documentation of this test, along with an additional TB skin test given within 3 months of enrollment.
B.
Positive TB Testing/Latent Tuberculosis Infection – new or previous (+) TB skin test or Blood Assay with negative Chest X-ray.
The majority of healthy persons infected with tuberculosis are able to contain the initial infection, though viable TB
microorganisms will remain present in their lungs for the rest of their life (latent tuberculosis infection or LTBI). Persons with LTBI
are asymptomatic, not contagious, and will have a normal chest x-ray. Their only evidence of infection will be a positive TB skin
test and/or blood assay (BAMT). Therefore, a negative chest x-ray does not rule out the presence of TB or the need for
treatment. About 5-10% will develop active pulmonary tuberculosis at some point in their life, most often during the first few
years after infection. Anti-tuberculosis medication decreases the chance of developing active TB infection by up to 90%. Persons
with (+) skin tests and/or blood assays for TB are required to have been evaluated by the health department to determine their
TB status and the need for preventive treatment. Provide:
•
Documentation of your TB testing (TB Skin Test or Blood Assay)
•
Chest X-ray Report (done after + TB testing)
*
Foreign-born students with positive TB skin testing who have received the BCG
vaccine, should get a Blood Assay for Tuberculosis/ BAMT (QuantiFERON® TB Gold or T-SPOT) for further evaluation. If BAMT is
positive for TB, then a chest x- ray, TB Symptom Survey, and evaluation by the Health Department is required. If BAMT is
negative, it may obviate the need for getting a chest x-ray.
•
TB Symptom Survey
•
Evaluation by the health department +/- the records of your preventive treatment. If LTBI is not treated, provide reason.
C. History of Active Tuberculosis - Required documentation includes:
•
Documentation of positive TB test (TB Skin Test or Blood Assay)
•
Chest X-ray Report (done after + TB test)
•
TB Symptom Survey
•
Health Department records of your TB treatment (Medications, Dates of Treatment, etc.).
8. Influenza (Flu) Vaccine* - is a mandatory vaccine for students who will be on MUSC campus from November through May. The seasonal flu
vaccine is usually released by about September, ahead of the flu season, and is composed of viruses that are predicted to be circulating the fall of
the year the vaccine is released through spring of the following year. So, while it is not a pre-matriculation requirement for students enrolling in
the Summer (May-July) or Fall (August), it is mandatory for those students to have received it by November*. Vaccines from previous flu seasons
will not satisfy this mandatory vaccine requirement.
*some colleges may have a different fall due date to accommodate clinical rotation sites
Name: ________________Date of Birth: _______________ College:___________________
Acceptable Documentation:
INSTRUCTIONS FOR COMPLETION OF IMMUNIZATION FORM
• Medical records from the provider that administered the immunizations, state issued records, employee health records and immunizations administered at a college. Previous college health forms are only
acceptable for the vaccines they administered. Supporting documentation must be included for every vaccine required.
• Immunization documents must contain the signature or stamp of the providing facility, must be in English, and must be legible.
• All dates must include the month, day, year (mm/dd/yy).
• Copies of the original lab report (with values/indices/reference ranges which indicate if immunity is present) must accompany this form.
NOTE: Computer print-outs of transcribed titer results from a health clinic is not acceptable. Re-vaccination may be required for IgG Antibody titers that are non-immune. In lieu of antibody titers,
documentation of age appropriate vaccination (MMR, Varicella) is acceptable proof of immunity.
Unacceptable Documentation:
• Lab reports with ambiguous results - Unacceptable results (“Reactive”, “Antibody Detected”, “Positive”), unless the reference range on the lab document indicates these results indicate immunity.
• Partial dates – must include month/day/year (mm/dd/yy).
• Parental signatures verifying vaccination.
MEDICAL CONTRAINDICATION TO REQUIRED VACCINES – a written statement from a qualified healthcare provider is required indicating the adverse reaction or medical circumstances
for which immunization is not considered safe.
1 . MEASLES (Rubeola), MUMPS, RUBELLA (German Measles) IMMUNE IgG Antibody Titers (copy of lab report required) or MMR Vaccines as indicated below.
*Students born on or after 01/01/1957 : Immune IgG MMR Titers or TWO MMR Vaccines received on or after age of 12 months AND both after 12/31/67
*Students born on or before 12/31/1956 : Immune IgG MMR Titers or ONE MMR Vaccine received after 12/31/67
ANTIBODY TITER
MONTH / DAY / YEAR
TITER RESULTS :
Measles / Rubeola IgG
□ Immune
□ Negative / Non-Immune
□ Lab Report Attached
Mumps IgG
□ Immune
□ Negative / Non-Immune
□ Lab Report Attached
Rubella IgG
□ Immune
□ Negative / Non-Immune
□ Lab Report Attached
MMR VACCINES
MONTH / DAY / YEAR
Verifying Documentation Attached
#1 Measles--
-
Mumps--
-
Rubella
#2 Measles--
-
Mumps--
-
Rubella
2. VARICELLA (CHICKEN POX) IMMUNE IgG Antibody Titer (copy of lab report required) OR VACCINATION - 2 Varicella Vaccines (Varivax)given 4-8 weeks apart). Varivax first available 3/17/95.
ANTIBODY TITER
MONTH / DAY / YEAR
TITER RESULTS : Negative / Equivocal / Borderline / Indeterminate Titer requires vaccination.
Varicella IgG Titer:
□ Immune
□ Negative / Non-Immune
□ Lab Report Attached
VARICELLA VACCINES
MONTH / DAY / YEAR
Verifying Documentation Attached
#1 Varivax
#2 Varivax
3. TETANUS/DIPHTHERIA/PERTUSSIS (Tdap): “Adacel” or “Boostrix”) first available 5/3/2005.
After a one-time dose of ADULT Tdap , Tetanus/Diphtheria (Td) boosters can be resumed. ONLY Exception for Tdap requirement is documentation of PERTUSSIS ALLERGY from healthcare provider.
TETANUS VACCINES
MONTH / DAY / YEAR
Verifying Documentation Attached
Tetanus/Diphtheria/Pertussis (Tdap)
Tetanus/Diphtheria (Td)
4. Meningitis Vaccine
Proof of Vaccination after age 16
OR Signed Waiver
MONTH / DAY / YEAR
Menactra Menveo Menomune Unknown (Attach Documentation of Vaccination )
I do not wish to receive the meningococcal vaccine. I have read the information and completed the on-line form at https://lifenet.musc.edu
5. Hepatitis B Vaccine Series AND Immune Titer: Required for individuals who may have exposure to blood or human body fluids (Patient Care, Lab duties, etc.)
Primary
Hepatitis B Vaccine
Series
Dose #1
/ /
MONTH/ DAY / YEAR
Dose #2
/ /
MONTH/ DAY / YEAR
Dose #3
/ /
MONTH/ DAY / YEAR
Attach documentation of vaccination
Hepatitis B Surface IgG
Antibody Titer
Date
Immune Titer
Non – Immune Titer
Lab Report Attached
Equivocal/Borderline
Negative
mIU/mL
Titer Result
Equivocal or Negative Titers – see Page 1
Dose #4
Dose #5
Dose #6
Secondary
Hepatitis B Vaccine
Series
(If Non-Immune After Primary Series)
/ /
MONTH/ DAY / YEAR
/ /
MONTH/ DAY / YEAR
/ /
MONTH/ DAY / YEAR
Attach documentation of vaccination
Hepatitis B Surface IgG
Antibody Titer
Date
Immune Titer
Non – Immune Titer
Lab Report Attached
Equivocal/Borderline
Negative
mIU/mL
Equivocal or Negative Titers – see Page 1
Titer Result
Hepatitis B Vaccine Non-responder
(If Hepatitis B Surface Antibody Negative after
Primary and Secondary Series)
Date:
Hepatitis B Surface Antigen
(If 2
nd
titer is negative)
(Attach Lab Report)
Date:
Hepatitis B Core Antibody
(If 2
nd
titer is negative)
(Attach Lab Report)
Chronic Active Hepatitis B
Date:
Hepatitis B Surface Antigen
(Attach Lab Reports)
Date:
Hepatitis B Viral Load (PCR)
Name: Date of Birth: College:
Tuberculosis Screening
All students must complete one of the TB Sections (A, B, or C) below. Results of TB screening tests (TB Skin Test or Blood Assay) required of
all students regardless of prior BCG vaccination. Do not have a TB skin test placed within 28 days of receiving a live vaccine (MMR or
Varicella) – this can give a false negative result. Follow instructions on cover sheet to complete the appropriate section on this form.
SECTION A
Negative Baseline Tuberculosis Screening
Date Placed
Date Read
Result
Documentation
TB Skin Test #1
/ /
/ /
mm Induration
Pos Neg Equiv
Copy of Report Attached
Skin TB Test #2
/ /
/ /
mm Induration
Pos Neg Equiv
Copy of Report Attached
TB Blood Assay
Date
Result
QuantiFERON® TB Gold
T-SPOT
/ /
Negative
Indeterminate
Copy of Report Attached
SECTION B
Positive TB Testing With Negative
*
Chest X-Ray
Positive TB Testing
*Persons born outside the US who have received the BCG vaccine are required to provide documentation of TB screening tests. Those with + TB skin tests should receive a
TB Blood Assay (Quantiferon or T-Spot). If TB Blood Assay is +, then a chest x-ray, TB Symptom Survey, and evaluation by Health Department are required prior to
enrollment.
TB Skin Test (≥ 10 mm)
And/Or
TB Blood Assay
Date Placed
/ /
Date Read
/ /
Result
mm Induration
Copy of Report Attached
Test
QuantiFERON® TB Gold
T-SPOT
Test Date
/ /
Results
Copy of Report Attached
Chest X-Ray (CXR)
(Taken after + TB Test)
Date of CXR
/ /
CXR Reading: Normal (No Evidence of TB)
Abnormal
Copy of Report Attached
Health Dept
Evaluation?
YES NO
Date of Evaluation:
/ /
Recommendation:
Copy of Report Attached
Prophylactic Treatment
For Latent TB?
YES
NO
Provide Reason Not Treated
Tx Started: / /
Tx Ended: / /
Medication(s):
Copy of Report Attached
TB Symptom Survey
Date Of Survey:
/ /
Any “Yes” Responses to Symptoms on TB Survey?
Yes No
Copy of Survey Attached
Section C
History of Active Tuberculosis Infection
TB Skin Test (≥ 10 mm)
Date Placed
/ /
Date Read
/ /
Result
mm Induration
Copy of Report Attached
TB Blood Assay
Test
QuantiFERON® TB Gold
T-SPOT
Test Date
/ /
Results
Copy of Report Attached
Chest X-Ray (CXR)
(Taken after + TB Test)
Date of CXR
/ /
CXR Reading:
Copy of Report Attached
Report from Health
Department Required
Date of Evaluation: / /
Recommendation:
Copy of Report Attached
TB Treatment
Medication(s):
Tx Started: / /
Tx Ended: / /
Copy of Health Dept Report
TB Symptom Survey
Date Of Survey:
/ /
Any “Yes” Responses to Symptoms on TB Survey?
Yes No
Copy of Survey Attached
Name: Date of Birth: College:
OPTIONAL IMMUNIZATION DOCUMENTATION
Immunization requirements may vary for students doing clinical rotations at institutions outside MUSC or who will be
participating in foreign travel (e.g. medical mission trips, etc.). Some will require documentation of childhood vaccine series
(Polio, DPT, etc.). Having this documentation available will assist Student Health complete the necessary forms to clear you for
these activities. If you anticipate participation in clinical activities outside MUSC and would like to have this information
available to Student Health, please provide documentation of these immunizations and complete the following section(s).
Diphtheria/Tetanus/Pertussis – Initial Childhood Series
Diphtheria/Tetanus/Pertussis –
Initial Childhood Series
DPT / DTaP / TD (circle one)
Date Administered / /
DPT / DTaP / TD (circle one)
Date Administered / /
DPT / DTaP / TD (circle one)
Date Administered / /
DPT / DTaP / TD (circle one)
Date Administered / /
DPT / DTaP / TD (circle one)
Date Administered / /
Polio Series
Polio
OPV / IPV (circle one)
Date Administered / /
OPV / IPV (circle one)
Date Administered / /
OPV / IPV (circle one)
Date Administered / /
OPV / IPV (circle one)
Date Administered / /
OPV / IPV (circle one)
Date Administered / /
Covid- 19
Date Administered / /
Vaccine Name:
Date Administered / /
Vaccine Name:
Date Administered / /
Vaccine Name:
Date Administered / /
Vaccine Name:
Name: Date of Birth: College:
Hepatitis A
Dose 1
Dose 2
Month/Day/Year Of Vaccine
/ /
/ /
HAVRIX
VAQTA
HAVRIX
VAQTA
Dose 1
Dose 2
Dose 3
Month/Day/Year Of Vaccine
/ /
/ /
/ /
Other Vaccines
Date (mm/dd/yyyy)
Partial dates are not accepted
Pneumococcal Vaccine
Pneumovax 0.5 cc
/ /
Pneumovax 0.5 cc
/ /
Other Vaccines
IPOL (Inactivated Polio Vaccine) 0.5cc Adult
Booster
/ /
Typhoid Oral Vaccine (Ty21a) x 4 capsules
/ /
Typhim Vi (ViCPS) 0.5cc
/ /
Yellow Fever Vaccine (YF-VAX) 0.5cc
/ /
Miscellaneous Vaccines
Please attach any additional vaccines with vaccine/dates/verification information.
*Upload your completed form and documentation to Lifenet at https://lifenet.musc.edu by selecting
“MEDICAL CLEARANCES” on the left-hand column on the home screen. Here you will see each of the
requirements listed and a button where you can “UPDATE” them. Click the “UPDATE” button next to each
requirement and enter the dates of your immunizations, titers, and TB tests or answer the questions
presented. You are also required to upload the documentation to support the dates you entered. To do
this you will click on the “UPDATE” button next to the “IMMUNIZATION RECORDS” requirement then click
on the “UPLOAD” button inside and add your files.
*Once you have entered your information and uploaded the form and documentation, a member of the
Student Health staff will review your immunizations for compliance and you will be notified through
Lifenet messaging if your records are complete or if you have any deficiencies.
*If you still have questions after reading the directions and the pre-matriculation form carefully, please
send an email to shsimmunizati[email protected]
Human Papilloma Virus (HPV)
Cervarix (2vHPV)
Gardasil (4vHPV)
Gardasil (9vHPV)