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
