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Health/Immunity Requirements For Volunteers |
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| Evidence of immunity is a requirement for providing patient care at Children's Hospitals and Clinics of Minnesota. Please complete the questions below. If no options can be selected for any disease, you must obtain vaccine/serology/mantoux from your primary care provider and document here. |
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| *1. |
TUBERCULOSIS - one of the following is required: |
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Negative Mantoux within the last 12 months |
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Date: MM/DD/YYYY |
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Negative chest x-ray (follow-up for + Mantoux) |
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Date: MM/DD/YYYY |
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Treatment for active disease |
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Date: MM/DD/YYYY |
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| *2. |
Immunity to CHICKENPOX (varicella) defined as one of the following: |
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History of chickenpox infection or shingles |
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Lived in same household as someone with active chickenpox |
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Positive serology indicating immunity to chickenpox |
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Date: MM/DD/YYYY |
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If vaccinated prior to age 13 - ONE dose of varicella vaccine |
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Date: MM/DD/YYYY |
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If vaccinated when 13 years or older; Two does of chicken pox vaccine |
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Date: MM/DD/YYYY |
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Date: MM/DD/YYYY |
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| *3. |
Immunity to MEASLES (rubeola) defined as one of the following: |
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Positive serology (antibody test) indicating immunity to measles |
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Date: MM/DD/YYYY |
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Date of birth before 1/1/1957 |
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Reliable History of Measles |
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One dose of vaccine (MMR, MR, or Measles) |
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Date: MM/DD/YYYY |
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Date of birth 1/1/1957 or later |
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MD diagnosis of measles |
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Two doses of vaccine (MMR, MR, Measles) |
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Date: MM/DD/YYYY |
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Date: MM/DD/YYYY |
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| *4. |
Immunity to RUBELLA defined as one of the following: |
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Positive serology (anitbody test) indicating immunity to rubella |
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Date: MM/DD/YYYY |
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One dose of vaccine (MMR, MR, rubella) |
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Date: MM/DD/YYYY |
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| *5. |
Immunity to MUMPS defined as one of the following: |
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Date of birth before 1/1/1957 |
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MD diagnosis of mumps |
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Positive serology (antibody test) indicating immunity to mumps |
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Date: MM/DD/YYYY |
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At least one dose of vaccine (MMR, or mumps) |
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Date: MM/DD/YYYY |
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Immunity status unknown (note: immunity recommended, not required) |
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| *6. |
Immunity to HEPATITIS B defined as one of the following: |
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Completion of vaccine series |
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Date: MM/DD/YYYY |
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Positive serology (antibody test) indicating immunity to hepatitis B |
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Date: MM/DD/YYYY |
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Immunity status unknown (note: immunity recommended) |
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I understand that Hepatitis B vaccine is strongly recommended for health care workers, but decline vaccination. |
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| *Physician's Name *Phone |
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