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Vanderbilt Occupational Health Screening Form for Observers
Scan documents and email to VOE@vanderbilt.edu or FAX: 615/936-0308
Name: __________________________________________ Date of Birth: ____/____/_______
HEALTHCARE PROVIDER MUST COMPLETE (NOT OBSERVER)
INITIAL ONE OPTION IN EACH SECTION
PROVIDE DATES WHERE INDICATED
MEASLES, MUMPS AND RUBELLA
Two (2) doses of MMR vaccine after first birthday (vaccine dates: )
Serologic proof of immunity to measles, mumps and rubella
(lab dates: measles
mumps
rubella_ _)
Pt born prior to 1957 and has positive immunity to rubella (lab date: )
VARICELLA (A history of the disease is insufficient proof of immunity. Proof of immunity is only accepted via one of the
following:)
Documented serologic immunity to varicella (lab date: )
Two(2) doses of varicella vaccine (vaccine dates: )
HEPATITIS B
Three (3) doses of hepatitis B vaccines
Series begun; has had of (3) Hepatitis B immunizations
Wishes to decline vaccine.
PERTUSSIS (required if observing in Pediatric, Emergency, and Women’s Health departments)
One dose of Tdap vaccine. (vaccine date: ________)
Note: DTP/DTaP and Td/TD vaccines do not meet this requirement.
TUBERCULOSIS
TB skin test or IGRA positive:
Chest X-ray has no evidence of active TB AND Treatment for latent TB infection was offered
(X-ray must be more recent than 6 months prior to observation start date. X-ray date: )
TB skin test negative or IGRA negative:
Date of TB Skin Test (must be within 1 year of observation date)
INFLUENZA
(Applicable if observer will be on the Vanderbilt University campus for any portion of the time period between October 1
and March 31; conversely, not applicable if the observer will not be on campus during that window of time.)
Annual Influenza Vaccination (vaccine date: - which must be between July 1 and March 31 of the
respective annual influenza season.)
I attest that I have reviewed the original documentation for all vaccines, X-rays and lab tests marked above
and that the information is complete and accurate to the best of my knowledge:
Healthcare Provider Printed Name Date
Healthcare Provider Signature
Office Phone Number ( )
Office Address
Mandatory: Add Office or Healthcare Provider Stamp
