Microsoft Word - SHP revised 12-9-22.docx

Immunization, Health History and

Physical Examination Information

Dear Student:

A complete health history, physical examination, serum blood titers, Tuberculosis clearance,

immunization records (since childhood), COVID-19 vaccination record, a Tdap vaccine and

completion of all the attached forms is required prior to registration at Western University of

Health Sciences (WesternU).

WesternU requires initial vaccination(s) and 1

booster against COVID-19. Please provide a

copy of the shot records in your health packet. If you want to know more about COVID-19

vaccinations, please visit https://www.westernu.edu/health/covid-19/vaccine-policy/ , or

discuss it with your healthcare provider or pharmacist.

NOTE:

The completed health clearance packet is due no later than 30 days before class registration

opens (please visit https://www.westernu.edu/registrar/registrar-about/registration-

information/ to check your registration dates).

Please note that it will take at least 10-business days to process your documents and to

release the hold that would prevent you from registering for your classes.

All documents are processed on a first-come-first-served basis.

You only need to contact the Student Health Office (SHO) if you have not received an email

or phone call from us 10 business days or more after you have submitted all your health

clearance documents.

Scan and Email Completed Health Packet in PDF format to:

stu-emphealth@westernu.edu

(SHO does not have a portal)

For questions, please email us at the above email address or call 909-706-3830.

Immunization, Health History and

Physical Examination Information

HEALTH

CLEARANCE

“TO

DO”

LIST

Take the Health Clearance Packet and forms with you every time you visit your Healthcare Provider

appointment with your Healthcare Provider (can only be one of the following: MD/DO/NP/PA):

 Physical Examination (Form C1-C2): make sure form is filled out and signed by your Healthcare provider.

 Order the following serum blood titers (any quantitative result must have reference ranges to be accepted

NOTE: only a QUANTITATIVE result will be

accepted

Hepatitis B (HbsAb, QN)

Can be either Qualitative or Quantitative

[if QN, must include reference range numbers]

Varicella (Varicella AB, IgG), Measles (Measles AB,

IgG, EIA) Mumps (Mumps AB, IgG), Rubella (MMR

AB, IgG)

 A Tdap vaccine obtained within the last 10 years. A TD or Dtap will not be accepted.

 Obtain/complete COVID-19 vaccination

 Tuberculosis Clearance must be one of the following:

- 1

TB skin test administered (must be read after 48 to 72 hours after administration).

- IGRA blood test [preferred if you have had a BCG vaccine in the past], e.g., Quantiferon or T-spot Test

(valid at WesternU for 4 years).

- Chest x-ray: required only if you have history of positive TB skin test or if your IGRA test is positive.

appointment with your Healthcare Provider:

 Review titer results and obtain copy of all actual lab results and, if performed, Chest X-ray report.

 Receive immunizations, if indicated, and provide documentation of administration.

 Tuberculosis Clearance:

- TB skin test: results are read and must be a number, e.g., 0 mm, the words “negative” or “positive” will

not be accepted.

IGRA: (e.g., Quantiferon or T-spot) test lab report and completed TB Symptoms

Health

Screening Checklist form, signed/dated by your Healthcare Provider.

- Chest x-ray: radiology report and completed TB Symptoms Health Screening Checklist form,

signed/dated by your Healthcare Provider. Please provide documentation of positive skin test or IGRA

test results along with the report for the chest x-ray.

 Obtain copies of all your immunization records since childhood from your healthcare provider’s office,

high school, or previous university.

 All records/documents submitted must be either originals or clean, legible,

and clear copies. They must be formatted as PDF copy attachment, and not

shareable files (we do not accept SharePoint/Google Drive files).

 Send all your documents at one time via email

 Do not send your forms a few pages at a time as they can be misplaced.

 Do not depend on your healthcare provider’s office sending all your forms to us.

Form A: Student Information

This section to be completed by the student.

Please use ink and print clearly.

Name Date of Birth

Last First Middle

WesternU Student ID# @ _______________________ Anticipated Year of Graduation: 20 _____

Program (circle the college you will be entering) :

COMP CA (California) College of Health Sciences: PA College of Optometry

COMP NW (Oregon) College of Health Sciences: PT CA (California) College of Pharmacy

College of Dentistry College of Health Sciences: PT NW (Oregon) Int’l Pharmacy (PIP)

Int’l Dental Program (IDP) College of Health Sciences: MSMS College of Podiatric Medicine

College of Graduate Nursing College of Health Sciences: OTD Int’l Podiatric Medicine (IPM)

College of Veterinary Medicine

Current Address:

Street Address

City State Zip/Province Code

Telephone Number: WesternU Email: @westernu.edu

Person to notify in case of an emergency/accident:

Name:

Last

First

Middle Initial

Relationship:

Address:

Street Address

City State/Country Zip/Province Code

Telephone:

Cell:

(Please include country code if telephone numbers are outside of the United States)

Email:

Signature of Student _____________________________ Date Signed __________________

Form B: Health History

This section to be completed by the student.

Please use ink and print clearly.

Name:

WesternU Student ID# @

Allergies (drugs/food):

Medications currently taking:

Place a check mark if you currently or have ever had any of the following:

HEAD

GASTROINTESTINAL

BLOOD

DISORDER

Major

dental

problems

Abdominal

pain

Anemia

Dizziness

Fainting

Recent

changes

appetite

Rheumatic

fever

Encephalitis

Recent

changes

bowel

habits

Sickle

cell

EYES

Recent

constipation

Lymphoma

Eye

trouble

Frequent

diarrhea

Other

Wear

glasses

Digestive

disorder

Wear

Contact

Lenses

Difficulty

swallowing

MENTAL HEALTH

EARS/NOSE/THROAT

Recurrent

emesis

(vomiting)

Frequent

nightmares

Allergies

Gastric

duodenal

ulcer

Trouble

concentrating

Ear

trouble

Hemorrhoids/Rectal

fissures

Cry

often

Hearing

problem

Other

ano

rectal

disorder

Feeling of

depression

Frequent

nosebleeds

Hernia

Tendency

worry

Hay

fever

Intestinal

worms

Memory

loss

Frequent

sore

throat

Jaundice

Mental

health

disorder

ENDOCRINE

Black

bowel

movements

Feelings

loneliness

Hypothyroid

Vomiting

blood

Considerable

nervousness

Hyperthyroid

Intestinal

inflammation

Difficulty

sleeping

Diabetes

mellitus

Gall

bladder

disease

Considered

suicide

CHEST/HEART/LUNGS/VASCULAR

Hepatitis

Lose

temper

often

Breast

disease or

masses

GENITOURINARY

Require

use

sleeping

aids

Chest pain/pressure

Urine contains

(circle):

Blood

Albumin

Sugar

Other

Heart

disease/murmur

Kidney

disease

ADDITIONAL

MEDICAL

HISTORY

High blood

pressure

Bladder

disease

Cancer

Rapid

irregular

pulse

Painful

urination

Unusual

fatigue

Varicose

veins

Frequent

urination

Frequent

colds

Asthma

Genital

disorder

Serious

illness

Chronic

cough

Prostate

gland

disorder

Sexual

problems

Emphysema

Frequent

urinary

tract

infections

Skin disorders/infections

Lung

disease

Other

Unexplained

weight

gain

loss

Night

sweats

FEMALES

ONLY

Other

Pleurisy

Abnormal pap

smear

SURGICAL

HISTORY

Wheezing

Ovarian

cysts

Appendectomy

Shortness

breath

Pelvic

inflammatory

disease

(PID)

Gall

bladder

Coughing

blood

Pregnancy:

Pelvic

surgery

INFECTIOUS

DISEASE

Painful

menses

(dysmenorrhea)

Cesarean

section

Ambiasis

Fibrocystic

disease

Tonsillectomy

Chicken

pox

Other

Coccidiomycosis

(Valley

Fever)

Encephalitis

SOCIAL

HISTORY

Hepatitis

Smoke tobacco

Histoplasmosis

MUSCULOSKELETAL

Alcohol

use

Intestinal Parasitic infection

Arthritis

Other

Malaria

Chronic

muscle

pain

Measles

Spine

problem,

e.g.,

disc

vertebrae

Please

explain

any

areas

that

you

checked or

may

not

Meningitis

Swollen

painful

joints/extremities

Mononucleosis

Bone

infection

Mumps

Amputation

Prior

BCG

vaccine

Prior

positive

PPD

Rheumatic

fever

NEUROLOGICAL

Rubella

Speech

defect

Scarlet

fever

Cluster

headache

Sexually

transmitted disease

Migraine

headaches

Tuberculosis

Paralysis,

tremors,

muscle

weakness

Neuralgia

numbness

Seizures

Form C-1: Physical Examination

This section to be completed by the DO, MD, NP, or PA only.

Name: WesternU Student ID#:

Date of Exam: Ht:

Wt:

BP: /

Pulse: Resp: Vision: R / 20 L / 20 Corrected / Uncorrected (circle)

Detailed

Description

ABNORMAL

Findings

GENERAL:

Posture, gait, speech, appearance

HEAD:

Hair, symmetry, tenderness

EYES:

Lids, sclera, conjunctiva, muscles, cornea, pupils, fundi, peripheral fields

EARS:

Pinna, canal, drum, hearing

NOSE:

Septum, obstruction, mucosa

MOUTH/THROAT:

Breath, lips, teeth, tongue, mucosa, pharynx, tonsils

NECK:

Thyroid, motion, trachea, veins

LYMPHATICS:

Cervical, supraclavicular, axillary, inguinal

CHEST/LUNGS:

Symmetric, percussion, excursion, breath sounds

CARDIOVASCULAR:

PMI, Rate, Rhythm, Sound, Murmur, Neck Bruits, upper ext.

pulses, lower ext. pulses, leg veins, edema, abdominal bruit

Tenderness, organs, hernia, masses, sounds, scars

MUSCULOSKELETAL:

Back, upper extremities, lower extremities

SKIN:

Birthmarks, rashes, scars, texture

NEUROLOGIC:

DTRs: Biceps, Triceps, Patella, Ankle, Romberg, Babinski, Cranial

Nerves, sensory, coordination, tremor, vibratory

MENTAL

STATUS:

ALOC x 3, affect, judgment, cognition, memory,

abstraction, hallucination/delusions

Breasts, Rectal, Gyn and male GU are not required to be examined

The

physical exam

can

than

months

old

from

date

you

will begin

classes.

Name WesternU Student ID#:

Last

First

Middle

Other Findings:

Are there any restrictions on physical activity?

Yes If yes, please explain:

Are there any recommendations for continued medical care/follow up?

Yes If yes, please explain:

____________________________________________________________________________________________________

Tdap vaccination (tetanus/diphtheria/acellular pertussis) date : _____________________________

NOTE: A TD and/or Dtap will NOT be accepted.

Immunization records

Student must submit immunization records beginning in childhood and COVID-19 vaccination card.

Tuberculosis Clearance

1. No history of positive TB skin test or IGRA must submit one of the following:

 TB PPD skin test. If you have not had 2 separate TB (PPD) skin tests completed within the past year, then 2 separate TB (PPD)

skin tests

at least 10 days apart from the 1

PPD being administered

is required.

Date 1

PPD Placed: Date 1

PPD Read:

Results of 1

PPD: Nurse Signature ________________

Millimeters of Induration

(the words “negative” or “positive” are unacceptable)

Date 2

PPD Placed: Date 2

PPD Read:

Results of 1

PPD: Nurse Signature ________________

Millimeters of Induration

(the words “negative” or “positive” are unacceptable)

Having a history of receiving the BCG vaccine alone is not acceptable as a positive PPD history unless a skin test has been

given and the result was 10mm or greater.

 IGRA (e.g., Quantiferon or T-spot) Date: ___________________ this is the preferred test if history of receiving BCG

vaccine. Must not be more than 6 months from the first day of matriculation. Must submit IGRA lab. results and a

completed TB Symptoms Health Screening checklist. (Note: This test is valid for 4 years at WesternU)

2. Positive history of TB skin test and/or IGRA must submit:

Chest x-ray/radiology Date: ________________________________ must not be more than 6 months from the first day of

matriculation. Must submit Radiology report, complete TB Symptoms Health Screening checklist, and provide

documentation of previous positive TB skin test and/or IGRA results. (Note: This test is valid for 4 years at WesternU)

Form C-2: Physical Examination

This

section

completed

DO,

MD,

NP,

or PA

Healthcare provider name (printed/stamped):

______________________________________________________________

Signature:

Date:

Address of Healthcare provider:

______________________________________________________________________________________________________

Phone number (please include country code if outside of

USA): ________________________________________________

Name WesternU Student ID#:

1. Hepatitis B Surf Ab, Quantitative QN] Only a QUANTITATIVE titer result will be accepted.

 Titer immune—no additional vaccine necessary

 Titer non-immune/low immunity—If you only completed the 1

Hep B vaccine series, then you are required

to restart the 2

series.

**NOTE: If you need to be revaccinated, you can go ahead and submit your documents as soon as you have received the 1

Hepatitis B vaccine. If you have received two complete Hepatitis B series and the titer still shows no immunity, then you

must provide proof of two complete vaccination series before you can be declared a Hepatitis B non-converter. Once

declared a non-converter, you will not be required to receive any more Hepatitis B vaccines.

Hepatitis B Carrier **Known Hepatitis B carriers are required to have the additional blood tests listed below and

the results must be included in the health clearance documents you submit.

Date: Hepatitis B Surface Ag, Hepatitis B core Ab, and Hepatitis Be Ag

2. Measles, Mumps and Rubella (MMR)

a. Measles (Rubeola) AB, IgG, EIA

b. Mumps Antibodies, IgG

c. Rubella Antibodies, IgG

 Titer positive/reactive—no additional vaccine necessary.

 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received 2

MMR vaccines—1 MMR vaccine is recommended.

 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you only

received 1 MMR vaccine—1 MMR vaccine is required.

 Titer negative/non-reactive/inconclusive/equivocal, and you do not have a documentation showing you

received 2 MMR vaccines—2 MMR vaccines required at least 30 days apart.

3. Varicella IgG AB

 Titer positive/reactive—no additional vaccine necessary.

 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received 2

Varicella vaccines—1 Varicella vaccine is recommended.

 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received 1

Varicella vaccine—1 Varicella vaccine is required.

 Titer negative/non-reactive/inconclusive/equivocal, and you do not have a documentation showing you

received 2 Varicella vaccines—2 Varicella vaccines required at least 30 days apart.

 Serum blood titers are NOT the same as vaccinations/immunizations.

 You must submit the actual laboratory reports for the above serum blood titers. Please

ensure that reference range are indicated on the quantitative results.

 Make sure to submit all vaccinations/immunizations records.

 Serum blood titers cannot be more than 1 year-old from the start of matriculation.

Form D: Immunization/Titer Results

COMP-CA COMP-OR Dental MSMS Nursing Optometry PT-CA PT-OR OTD PA Pharm Podiatry Vet Med

Student/Employee ID @____________________ Grad. Year: 20 _______

Name DOB

Address Phone:

City/State/Zip

Date of last PPD _______________________________________ PPD Results ______________ MM

Date of IGRA (e.g., Quantiferon/T-Spot) test: _____________________ Results): Negative Positive

Date of Last Chest X-Ray:_____________ Results: Positive for TB Negative for TB

1. Have you ever been told you have active tuberculosis? Yes No

2. Have you ever taken Isoniazid (INH) or Rifampin (RIF)? Yes No

3. Date and duration of medication regime (months)

4. Have you ever had BCG Vaccination? Yes No If yes, when? ________________________________

(If you have had the BCG vaccination, it is preferred that you obtain an IGRA [e.g., Quantiferon or T-spot test])

5. During the past year have you noticed (circle your answer):

Yes No Unexplained weight loss?

Yes No Decrease in your appetite?

Yes No Cough not associated with cold or flu?

Yes No Increase in AMOUNT of Sputum?

Yes No Change in COLOR of Sputum?

Yes No Change in CONSISTENCY of Sputum?

Yes No Blood Streaked Sputum?

Yes No Night sweats?

Yes No Unexplained low grade fever?

Yes No Unusual tiredness or fatigue?

Yes No Swelling of lymph nodes?

Yes No Have you had contact with a family member or partner who has been diagnosed with tuberculosis?

Yes No Have you or a member of your family been exposed to someone who is immune compromised?

Explain any “Yes” answers above:

List any on-going medical problem

_____________________________________________

Signature of Person Completing this form Date

o Plan of care, if indicated:

Must be reviewed by licensed healthcare provider if any “yes” answers

TB Symptoms Health Screening Checklist

This form only applies to those required to have a chest

x-ray or have had an IGRA (Quantiferon) test.

Signature of Reviewer: _____________________________________________________ Date

________

No further action needed

_________

Chest X

Ray Requeste

_________

Further Evaluation Needed

Annual Health Requirements Attestation

I, _________________________________ WesternU ID#: @ ____________ understand that:

(Printed Name of Student)

Tuberculosis Clearance

It is my responsibility to remember to renew my Tuberculosis clearance each year before it will expire.

 If my PPD skin test does expire, I know I will be required to complete 2 separate PPD skin tests,

10-days apart in order to be in compliance with the TB clearance protocol.

 I understand that if my TB clearance was completed by chest x-ray or IGRA serum blood test, I

must complete a TB symptoms checklist and submit it to the Student Health Office on a yearly

basis.

Annual Influenza Vaccination

I must obtain and submit proof of receiving the yearly Influenza vaccination no later than November 30

of each

year to the Student Health Office.

 I am also aware the only exception to this mandatory vaccination requirement is if there is a medical

contraindication and that a healthcare provider’s dated and signed note attesting to this fact must be

provided to the Student Health Office before the date noted above.

Hold Placed on Student Account

I am aware I will not be notified of a hold placed on my student account if my health clearance requirements are

not up to date.

 I also understand the hold will not be removed until I have submitted any outstanding items to the Student

Health Office.

 I understand that this means I will not be able to register for classes or obtain financial aid until the hold is

cleared.

By signing this attestation, I certify that I am fully aware of these health clearance requirements and agree

to comply with same.

Student Signature: _____________________________ Date: _____________________

Authorization for Release of Communicable Disease Clearance Information to

Clinical Rotation Sites

I, _______________________________________, WesternU ID#: @_______________ hereby authorize:

(Printed Name of Student)

Western University of Health Sciences

Student Health Office

100 W. Second St, Room 219

Pomona CA, 91766-1700

to release to the extent permitted by law, the following medical information that Western University of Health

Sciences (WesternU) now has in its possession, or that it may create or receive from any third party in the

future: Immunization information (including titer results); Tuberculosis clearance; History and Physical Exam

report

to any of the clinical rotation site(s)

that I am or will be assigned to as a student of WesternU and any

additional health clearance requirements that a clinical rotation site may require. I understand that this

information must be provided, if requested, in order to prove to a clinical rotation site that I meet all

communicable disease clearance requirements as required. I also understand that if I do not allow this

information to be provided to the various clinical rotation sites, a clinical rotation site can refuse to allow me

to rotate through its facility. I am also acknowledging that if I cannot complete the clinical rotations required

for my degree and/or licensure because of my refusal to authorize the release of my communicable disease

clearance information to the clinical rotation sites, I agree to hold WesternU harmless to the extent

permitted by law. I also am aware that this Authorization will remain in effect for the duration of my time as a

student at WesternU and will expire on the date of my graduation from the University.

By signing this Authorization, I agree with all the provisions stated in this Authorization for the release of

the specified information and continued health clearance requirements.

Student Signature ____________________________ Date ______________________

100 W. Second Street, Room 219

Pomona, CA 91766-1700

Tel: (909) 706-3830 Fax: (909) 706-3785

AUTHORIZATION FOR RELEASE OF STUDENT HEALTH CLEARANCE DOCUMENTS

College (please circle the college you will be entering) :

COMP CA (California) College of Health Sciences: PA College of Optometry

COMP NW (Oregon) College of Health Sciences: PT CA (California) College of Pharmacy

College of Dentistry College of Health Sciences: PT NW (Oregon) Int’l Pharmacy (PIP)

Int’l Dental Program (IDP) College of Health Sciences: MSMS College of Podiatric Medicine

College of Graduate Nursing College of Health Sciences: OTD Int’l Podiatric Medicine (IPM)

College of Veterinary Medicine

Student ID # @ __________________________________ Grad Year 20 _____________

Name

DOB

Address

Phone

City/State/Zip

A handwritten signature is required in order to activate this request.

Student Signature Date______________________

Note: A photocopy or electronic scan of this document shall be as valid as an original.

This Authorization is valid until otherwise notified in writing.

I hereby request and authorize that the

Student

Employee Health Office

email my Health Clearance Records to

my WesternU email address of:________________________@westernu.edu or to

________________________________

The Health Clearance Records I am authorizing for release include:

*Immunizations/Titers *Tuberculosis Clearance Documents *History and Physical Exam

Other:

NOTE: Unless lined out, those with an * will be sent to the email address you indicate

Health Clearance FAQs

Please carefully read the details below regarding the documentation you must provide in order to register for classes.

History and physical exam: must be within six (6) months of matriculation (first day of beginning your classes at

WesternU).

Serum blood titer reports: must be drawn within one (1) year of matriculation and show you are immune against

measles, mumps, rubella, varicella and Hepatitis B. Immunization records and/or “had the disease” alone will not be

accepted for these diseases. You must submit serum titer lab results that include reference ranges, along with your

immunization records. These records must show, at minimum, your name, the name of the vaccine and the date of

administration.

6. Rabies titer (applies to Veterinary Medicine students only): must be a Rapid Fluorescent Focus Inhibition Test

(known

as a RFFIT) and ONLY if the Rabies vaccine series were received/completed prior to enrolling for fall semester classes. Please

note the RFFIT is the only rabies titer we will accept. This titer is due no later than September 30

of the current year.

b. Based upon your health history or current health status, if a particular immunization is medically (temporarily/permanently)

contraindicated, a signed letter from your licensed healthcare provider attesting to this contraindication will be

acceptable. However, you will still be responsible for obtaining the immunization clearance as soon as your temporary

health

issue is resolved. You will not be cleared to start any clinical rotations without this clearance.

Hepatitis B vaccine series: if you have initiated the Hepatitis B vaccination series prior to starting classes, but have not

yet

completed the series, registration for your first semester of classes will not be delayed, if you

submit documentation showing

you have started the Hepatitis B vaccination series. However, you will need to submit

proof of receiving the remaining

vaccine(s)

as soon as they are due. You must also provide a Hepatitis B Surf AB QN titer, that was drawn at least 30-days after your last

Hepatitis B

vaccine.

Tetanus/Diphtheria/Acellular Pertussis (Tdap) booster: we require one documented Tdap booster within the last 10

years. An immunization record is required for this vaccination.

COVID-19 vaccination: you must provide proof of receiving/completing the initial vaccination series and booster. Medical

exemption, religious exception and pregnancy deferrals will be considered.

Tuberculosis (TB) clearance: YEARLY REQUIREMENT NOTE: If you need to have the 2-step (meaning 2 separate) PPD skin test,

they must be at least 10 days apart or they will not be accepted. It is your

responsibility to renew your yearly TB clearance

and submit it to Student Health before it expires. The only acceptable

TB clearance is one of the following:

Tuberculin Skin Test (commonly known as a PPD): PPD results must be read 48- to 72-hours after

administration and

the results must indicate millimeters of induration and not simply “negative” or “positive.” The

form must be dated and

signed by a licensed healthcare provider, or it will not be accepted.

IGRA lab test: reports cannot be more than 6 months from date of starting classes and must indicate qualitative

results.

This blood test is valid at WesternU for four (4) years however students must also submit a completed, signed and dated

TB Symptoms Health Screening checklist form on a yearly basis to

the Student Health Office. This test is preferred if you

have a history of having received a BCG vaccine.

Chest x-ray: If you have a prior history of latent TB infection (LTBI) as determined through a tuberculin skin test

(PPD) or a

blood test (IGRA), a licensed healthcare provider must provide a signed, written report that shows you do not

have active TB

disease. If a chest x-ray was required for TB clearance, a copy of the actual radiology report and a completed TB Symptoms

Health Screening checklist form must accompany your health clearance documents. Please note

that the chest x-ray cannot have

been taken more than 6-months prior to the start of your start of your classes.

a. Your healthcare

provider

MUST ORDER THE FOLLOWING

titers

meet

this

admission

requirement:

Hepatitis

Surf

(only

Quantitative

results

will

accepted,

must

include

reference

range

numbers)

The

lab

results

for

the

following

can

either

Qualitative

(QL)

Quantitative

(QN).

Measles

IGG,

EIA

Rubella

Antibodies,

IgG

Mumps

Antibodies,

IgG

Varicella

IgG

Prior history of active pulmonary TB: a licensed physician must provide a signed, written report that must show you

have

completed, or are in the process of completing, all required therapy. The report must include the name of the

medications,

dosages, frequency of administration, and total doses received. If you have completed the therapy, the report must state this fact,

including the date the treatment was completed. If your treatment is still in process, the report must state when it is expected to

be completed. Additionally, a chest x-ray report is required for admission clearance. You must provide a copy of the actual

radiology report and it cannot be more than 6-months old if: 1) you

have completed the treatment and/or, 2) from the day you

start class.

History of BCG vaccination: prior BCG vaccination is NOT a contraindication to either PPD or IGRA. IGRA test is preferred if you have

received a BCG vaccine in the past. In this setting, interpretation of the results of screening tests for TB infection will take into

account each of the following:

the length of time between past BCG vaccination and the screening test; and

the risk of infection with Mycobacterium tuberculosis.

Influenza vaccination: YEARLY REQUIREMENT—all students must receive the annual influenza vaccination every fall.

Documentation of receipt of this vaccination is required and must be submitted to the Student Health Office no later

than the

November 30

each year or a hold will be placed on your account. If you have a medical contraindication to receiving the

yearly influenza vaccine, a note from your healthcare provider on their letterhead, that is also signed/dated is required. An

email “letter” or “note” is not accepted.

Veterinary Students ONLY

Rabies vaccination: Students enrolling in the DVM program must provide all of the above documentation as well as

show

proof of having received the pre-exposure series of rabies immunization or agree to complete the rabies

vaccinations as

part of the University matriculation process no later than September 30

of the current year.

A pre-exposure series involves the administration of two (2) intramuscular doses of the vaccine given on days 0 and 7.

You can begin receiving your rabies vaccination series now or during orientation week on campus at the WesternU

Health Pharmacy. A fee is charged for each of the vaccines you have to receive. For pricing, please call 909-706-3730.

Students who have previously received the Rabies vaccine series may be excused from being re-vaccinated by

providing

official documentation from their healthcare provider stating the dates they received 2 rabies

vaccines. The serum RFFIT

titer (which measures level of immunity to rabies) must be done if the two (2) vaccines were received/completed prior

to enrolling for fall semester classes. The titer results is due no later than September 30

of the current year.

KEY POINTS

 No further health clearance reminders will be sent to you.

 It is your responsibility to keep track of items you are required to submit to the Student Health Office.

 If you fail to submit required documents when they are due, a hold will be placed on your account. This

means you will not be able to register for classes, receive financial aid payments, or obtain transcripts.

All records/documents submitted must be either originals or clean, legible, and clear copies. They must be

formatted as PDF copy attachment, and not shareable files (we do not accept SharePoint/Google Drive files).

Wrong format documents will be sent back to you.

If you have medical questions on any of the above, please consult with your personal healthcare provider.

If you have any additional question regarding the health clearance requirements, you may direct them to the Student Health Office

at stu-emphealth@westernu.edu or call us at 909-706-3830.

Q—Why do I need to submit my immunization records and serum titers?

A—Many clinical rotation sites that our student’s rotate through require copies of both your immunization records and serum titer

results. When you are preparing to start at a clinical rotation site that requires this information, you will just need to contact the Student

Health Office. (If you are having trouble locating your immunization records, you may want to check with your high

school/undergraduate college/university Health Center to see if they have a copy of your

vaccination history).

Q—If my healthcare provider writes a note stating I have had a communicable disease, is this acceptable?

A—No. Documentation of select communicable diseases that were “physician diagnosed” and not confirmed through blood tests, are

longer accepted as evidence of immunity. Because of this, the required vaccine preventable diseases that have blood tests to

determine if

immunity exists or not (referred to as titers), are required for hepatitis B, measles, mumps, rubella, and varicella.

Q—If my healthcare provider writes a note stating the student “is up-to-date on all vaccines,” is this acceptable?

A—No. Documentation requirements for your health records must show the specific dates you received the vaccines. Health records

may be

in the form of original vaccination records (or a clear copy) or a letter from the healthcare provider on their letterhead or

printed prescription

(no emails allowed) stating the vaccine name and dates each was administered. The letter must be signed by the

healthcare provider. We will

not accept school records, family member statements or baby book entries.

Q—If I get behind in a vaccination series (i.e., hepatitis B, MMR, or varicella), what should I do?

A—You will pick up where you left off and complete the vaccination series. For example, you received the first shot of the Hepatitis B vaccine

series, but you have not received the rest of the vaccine, your healthcare provider can determine what else may be needed. If you can show

you have started a vaccine series, you will be allowed to register for your first semester but until you provide proof you have completed

the series, you will not be allowed to register for any subsequent

semesters/classes.

Q—If I received a vaccine dose earlier than the minimum interval recommended, is this acceptable?

A—No it is not. The dose of vaccine is invalid and must be re-administered after the minimum interval has been met. For example, the

hepatitis B minimum intervals are as follows: Dose 1 is administered. Dose 2 should be separated from dose 1 by at least one month (4

weeks

or 28 days). Dose 3 should be separated from dose 2 by at least 2 months (8 weeks) AND from dose 1 by at least 4 months (16

weeks).

Q—Will vaccines interfere with my TB skin test (commonly known as a PPD) results?

A—Some vaccines may. For example, the MMR vaccine may interfere with PPD results (may have a false negative result in someone

who

has an infection with TB) if the vaccine is administered within 4-weeks of the PPD. However, the MMR vaccine can be

administered at the same time and on the same day as the PPD. The hepatitis B, tetanus and rabies vaccines can be administered any

time

without interfering with PPD results.

Q—How do I know if my 1

PPD will be accepted or counted?

A—If you have not had a PPD in more than one year, you are required to complete the 2-Step PPD process before your complete TB

clearance requirement has been met. The 2

PPD must be administered at least 10-days from the 1

PPD being administered.

Q—If I received the TB skin test at WesternU, can I have a healthcare provider at a non-WesternU clinical rotation site read the TB

skin

test results and document them?

A—If your clinical site is near a WesternU campus, then the answer is no. It must be read at WesternU and documentation must then

provided to the Student Health Office. However, if your clinical rotation site is not near the campus, you can

have the TB skin test

read by the Employee/Occupational Health nurse at the clinical facility you are rotating through. The results can be

faxed to 909-706-

3785 or scanned and emailed to stu-emphealth@westernu.edu

Q—Can I submit an IGRA (e.g., Quantiferon or T-spot) blood test for TB clearance?

A—Yes, if you do not have a history of a positive Tb skin test. The test cannot be more than 6 months from your first day of

matriculation. This test is valid at the university for 4 years.

However, you are still required to submit a completed TB Symptoms

Health Screening Checklist form on a yearly basis.

Q—Do I only have to complete a TB clearance on a yearly basis?

A—Yes. Be aware that some clinical rotations sites have more stringent TB clearance requirements that you must comply with in

order for you to be permitted to go to that site.

Immunizations, Tuberculosis Clearance & Titers

Q—Do I need to get a PPD if I have a history of a positive PPD?

A—No. You are required to obtain a chest x-ray (x-ray cannot be more than 6 months old from your first day of starting classes at

WesternU) and complete the TB Symptoms Health Screening Checklist included in this packet. We do not need the actual chest x-ray

film; we only need

the radiologist’s written report.

Q—I am healthy. Why should I be required to show that I have been immunized?

A—As members of the WesternU community, it is very important for all of us to be free from communicable diseases that can threaten

those

around us. Many of these diseases are preventable with appropriate vaccination. Also, in order for you to participate in your

required clinical rotations, you must be able to show proof that you are not at risk for contracting a vaccine preventable communicable

disease.

Q—If I received my second Hepatitis B vaccine (Engerix-B or Recombivax) later than recommended after the first vaccine, how soon

after getting the second

Hepatitis B vaccine can I receive the third and final Hepatitis B vaccine?

A—If you had the 2

vaccine several months after the first one, you can receive your 3

and final Hepatitis B vaccine 60-days a

fter the 2

vaccine. A serum blood titer is still required 30-days after vaccine number three.

Q—If I have completed 2 full Hepatitis B series and my titer is still showing I do not have immunity, do I need to complete another

series?

A—No, because most likely you are a non-converter, however, you will need to provide us with the documentation showing

that

you have completed 2 entire Hepatitis B vaccination series and a current Hepatitis B Surface Ab, QN titer.

Q—What is WesternU’s policy on COVID-19 vaccinations?

A—Please go to https://www.westernu.edu/media/health/pdfs/covid-19-vaccination-program-policy.pdf for current

information

Titers

Q—What titers should I ask my physician/healthcare provider to order?

A—Hepatitis B, Surf AB QN; Measles AB IgG, EIA; Rubella Antibodies, IgG; Mumps Antibodies, IgG; Varicella IgG AB.

NOTE: the

Hepatitis B titer results MUST be Quantitative and include the references ranges or we will not accept the test results.

Q—What should I do if the blood titers show I am not immune to the vaccine preventable disease(s)?

A—Unless you have a documented medical condition that contraindicates the administration of the vaccine(s), you may be required to be

vaccinated/revaccinated for those diseases that you have no immunity against. Please refer to Form D.

Q—When is a rabies titer needed?

If you are a veterinary medicine student who has already completed the rabies vaccination series (2 vaccines) prior to enrolling to fall

semester classes, you are required to have a rabies titer and submit the titer results along with the dates you received each of the rabies

vaccine. In accordance with the

Centers for Disease Control and Prevention (CDC), the recommended serum blood test for rabies is called

rapid fluorescent focus inhibition test (RFFIT). No other rabies testing results will be accepted. (CDC Rabies information:

http://cdc.gov/rabies/specific_groups/doctors/serology.html )

General Questions

Q—What would happen to me if I don’t complete the health clearance requirements?

A—Every incoming student, whether new to WesternU, repeating or returning from a leave of absence, is required to comply with all

health

clearance requirements. If you do not complete these requirements, a registration hold will be placed, or in extreme cases, your

acceptance to

attend WesternU may be rescinded.

Q—I am going to be returning to WesternU after being on a leave of absence for more than 6 months. Do I have to do the entire

health

clearance process?

A—If you have already submitted serum titers (as described/required in the health clearance packet) and immunizations records, then all

you

will need to submit is an updated medical history, physical exam, and TB clearance. Additionally, if your serum titers are more than

4 years old, you will need to have them repeated.

Q—If I have had the Hepatitis B disease and my physician states I do not need to have the Hepatitis B vaccination series, what should I

ask my physician to include in the health records and documents sent back to Western University?

A—Have your physician provide the lab test results that confirm a prior Hepatitis B diagnosis (see form D for the additional required serum

titers) and include a note about the status of your Hepatitis B disease [for example, “continue to monitor viral loads every 6 months”] on

the

History and Physical examination form your physician completes. (This would also apply to those persons who have a “native

immunity” to

Hepatitis B.)

Q—What if I have a health condition that is a contraindication to receiving a particular vaccination?

A—A letter from your healthcare provider attesting to this contraindication will be acceptable. However, if your current health status is

such

that a particular immunization is temporarily contraindicated, you will still be responsible for obtaining that immunization as soon

as your

health issue has resolved and prior to starting any clinical rotation.

Q—What if my religious beliefs do not allow me to be immunized?

A—Other than COVID-19 vaccines, there are no religious exemption from the University immunization requirements. One should

explore with his/her healthcare provider

for the availability of vaccine formulations that do not involve the use of blood or select animal

products, or document immunity as a result of prior infection. The University’s commitment to minimize the potential harm to you and

any patients or colleagues that you may encounter in your future career is of paramount concern to the university. Only a legitimate

medical contraindication to vaccination will exempt a student from the University’s immunization requirements.

Q—Can I participate in clinical rotations if I am still updating/completing the required vaccines and TB clearance?

A—In order for you to be able to start your clinical rotations you must be up to date on all your required vaccinations, TB clearance and

serum blood titers. You must provide proof that you have completed all of the communicable disease clearance requirements or you will

be removed from clinical rotations; will not be allowed to register for the next semester; and if you receive financial aid, you will not

receive your funds until these requirements have been fulfilled.

Q—If I am pregnant can I be vaccinated safely?

A—Some vaccines can be administered safely during pregnancy. However, it is recommended that you consult with your obstetrician

prior to receiving any vaccines.

Q—If I am pregnant, can I participate in my clinical rotations without having completed the required vaccinations?

A—A pregnant student can receive a temporary medical exemption and still participate in some clinical rotations. However, it is

strongly

recommended that you work closely with your faculty advisor to determine if it is permitted by the clinical site you

would be going to as well as your obstetrician.

Q—How long will it take to process my health clearance forms?

A—You will need to allow at least 10 (ten) business days from the date we receive all of your required health clearance forms. If you have

not received a confirmation email from the Student Health Office by the end of the 10

business day, you should contact us. Note: all forms

are processed on a first come, first served basis only.

Q—When is the deadline for submission of all my health clearance forms/documents?

A—The completed health clearance packet is due no later than 30 days before class registration open. Please visit

https://www.westernu.edu/registrar/registrar-about/registration-information/ to check your registration dates.

Q—Once I have submitted all health clearance documents, will I have to do any other communicable disease tests, receive more

immunizations or obtain a physical exam?

A—You are required to obtain a yearly influenza vaccination and complete annual TB clearance and submit the documents to SHO.

Additional tests, vaccines and physical exams may be required for a clinical rotation site. It is your responsibility to confirm what is

needed to clear you to rotate any site. Please provide copies of any additional health clearance document to the Student Health Office.

Q—If I am feeling overwhelmed or my stress level is increasing, is there some place on campus where can I get help?

A—We have a department referred to as LEAD. They specialize in six main topics that support students through their academic journey

here at WesternU. These areas include a) one-on-one academic counseling, b) tutoring, c) the annual Summer Preparedness and

Readiness Course (SPaRC), d) the Wellbeing Initiative, e) LEAD CALM – Mindfulness Meditation Training & Practice, and f) various

workshops relevant to student life. All LEAD services are free of charge to the WesternU community, and all services are completely

confidential.

If you need access to emergency student resources, call one of the following 24/7 hotlines:

 Optum counseling number is 800-234-5465

 Sexual assault hotline is 909-626-4357

 Suicide prevention hotline is 988 or go to Behavioral Health Assistance Programs for more information.

Services available on the Pomona Campus

Cost of physical examination and serum blood titers depends on your health insurance pricing and deductible.

Please contact your health insurance for further information.

NOTE: If you chose to have your labs drawn at a facility other than the WesternU Health Medical Center, and you

do not want to go to your healthcare provider’s office, you must obtain the lab order from the Student Health

Office BEFORE going to an outside lab for your blood draw.

Please note all prices listed may change without any notice.

For current pricing, contact the center at the numbers listed above.

WesternU Health: Medical Center*

795 E. Second Street, Suite 5

Pomona, CA 91766-2007

909-865-2565

Services Provided Appointment is Required

 Physical Examinations Open: Monday-Friday

 Serum blood titers Hours: 8am to 5pm

WesternU Health Pharmacy

795 E. Second Street, Suite 1

Pomona, CA 91766-2007

909-706-3730

Services Provided NO appointment required

 Vaccinations Monday-Friday

 TB skin test 8am to 430pm

Vaccine

Dose

Price

Hepatitis B Vaccine (Engerix

0, 1, 6 months

$90

Hepatitis B

Vaccine (Heplisav

B 2 dose)

0, 1 month

$130

Measles, Mumps, and Rubella Vaccine

1 or 2

$98

PPD/TB

(Tubersol)

1 or 2

$25

Rabies Vaccine (Rabavert)

0, 7 days

$363

Tetanus, Diphtheria, and Acellular Pertussis

(Boostrix)

$69

Influenza Quadrivalent

$35

Varicella Virus Vaccine Live (Varivax)

1 or 2

$182