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Health Screening Documentation

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COMMUNITY PARTNERSHIPS OBSERVATION/JOB SHADOW HEALTH SCREENING DOCUMENTATION ___________________________________ __________ Name Date ___________________________________ School (if applicable) Measles, Mumps, Rubella Immunity First Vaccination Date: Second Vaccination Date: OR MMR Titer Showing Immunity Date: Chicken Pox (Varicella) Immunity First Vaccination Date: Second Vaccination Date: OR Varicella Titer Showing Immunity Date: Annual Tuberculosis Screening (Dates Must Be Within the Past 12 Months) First Non-Reactive (0 mm) PPD Skin Test Date: Second Non-Reactive (0 mm) PPD Skin Test Date: OR Negative QuantiFERON-TB Gold Blood Test Date: OR If positive TB test, medical clearance, including x-ray result, from within the past 12 months Date: ___________________________________________ __________ Signature of School Nurse or Health Care Provider Date ___________________________________________ Printed Name of School Nurse or Health Care Provider

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