Page 1 of 4
/ /
/ _/
_/ _/ _
/ /
•
/ _/
/ /
/ /
/ /
/ /
_
2024-2025 Health Background Form
University at Buffalo Student Health Services
4350 Maple Road, Amherst, NY 14226
716-829-3316 Fax: 716-829-2564
• Form for all NEW INCOMING STUDENTS
• Returning health-related program students, use the Annual Immunization Review form
Students cannot register for classes until they have fulfilled the required immunizations
• Form must be completed and signed by a licensed health care provider or have immunization records attached.
• All immunization records must be in English.
•
S
ubmit to UB Student Health Services via the patient portal (
patientportal.buffalo.edu).
• E
xemption information can be reviewed at: www.buffalo.edu/studentlife/immunize
Name (please print): UB Person #:
Last First MI
Birthdate:
Month Day Year
Academic Program/Major:
Emergency Contact Name & Phone #:
FOR STUDENTS UNDER 18 YEARS OF AGE ONLY
To avoid delays when medical problems arise, we request that the following statement be signed by a parent or legal guardian:
I hereby grant permission to UB Student Health Services to provide services, including telemedicine, to my child. This includes care
and treatment by medical providers at any outside health care facility if deemed necessary by UB Student Health Services
.
Parent/Guardian Signature Relationship Date
Section 1. Required for ALL Students Submit dates in MM/DD/YYYY format
MMR (combined Measles, Mumps, Rubella)
• Two doses of MMR vaccine (given after 01/01/1968); both
administered after first birthday and at least 28 days
apart
OR
• Serology (blood test): Positive IgG antibody titers confirming
immunity to measles, mumps, and rubella
Dose #1
Dose #2
OR
MMR Titer Date
**MUST ATTACH LAB REPORTS WITH REFERENCE RANGE**
MENINGOCOCCAL VACCINE or WAIVER
New
York
State
requires
all
college
students
to:
•
Receive at least one dose of Meningococcal ACWY vaccine
within 5 years of entering college
OR
• Receive two doses (full series) of Meningococcal B vaccine
OR
• Receive two doses (full series) of Meningococcal ABCWY
OR
Sign a waiver specifically declining meningococcal
immunization
Men ACWY Dose #1
OR
Men B Dose #1
Men B Dose #2
OR
Men ABCWY Dose #1
Men ABCWY Dose #2
OR
I acknowledge the risks associated with meningococcal
infection (meningitis) and decline immunization at this time.
Signature Date
If student is under 18 years of age, parent/guardian must sign & date.
Page 2 of 4
_/ _/
_/ _/ _
_/ _/ _
_/ / _
/ /
/ /
_/ _/ _
_/ _/ _
/ /
_/ / _
/ /
_/ _/ _
_/ _/ _
_/ _/ _
_/ _/ _
_/ _/ _
_/ _/ _
_/ _/ _
_/ _/ _
_/ _/ _
/ /
/ /
/ /
Name (please print): UB Person #:
Last First MI
Section 2. Required for Health-Related Students
Recommended for All Other Students
Submit dates in MM/DD/YYYY format
New students enrolled (not intended) in health-related programs includes Athletic Training, Communicative Disorders, Dental, Dietetic Intern,
Exercise Science, Medicine, Medical Technology/Biotechnology, Nuclear Medicine, Nursing, Occupational Therapy, Pharmacy, Physical Therapy.
HEPATITIS B
• Three dose series (Heplisav-B only requires two doses)
OR
• Serology (blood test): Positive Hepatitis B Surface Antibody,
Quantitative Titer confirming immunity.
*Serology is REQUIRED for all first-year medical students. *
Dose #1 Circle if Heplisav-B
Dose #2 Circle if Heplisav-B
Dose #3
OR
H
epatitis B Titer Date
**MUST ATTACH QUANTITATIVE LAB REPORT
WITH REFERENCE RANGE**
TETANUS-DIPHTHERIA
• Tetanus (Td/Tdap) booster within last 10 years
• One lifetime adult Tdap (contains pertussis) is required
• Must complete both fields even if the date is the same
Last Tetanus Booster Date Circle: Td or Tdap
Adult Tdap Vaccine Date
**DATES REQUIRED FOR BOTH**
VARICELLA
Must demonstrate immunity through one of the following:
• Two doses of varicella vaccine; both administered after
first birthday and at least 28 days apart
OR
• Medical provider/clinician documented history of varicella
(chickenpox) disease
OR
• Serology (blood test): Positive varicella IgG antibody titer
confirming immunity
Dose #1
Dose #2
OR
Medical Provider/Clinician Diagnosis
OR
Varicella Titer Date
**MUST ATTACH LAB REPORT WITH REFERENCE RANGE**
INFLUENZA
•
•
One seasonal dose given annually. List most recent dose.
Include brand name on the line next to the dose date.
Section 3. Recommended for All Students Submit dates in MM/DD/YYYY format
HEPATITIS A
Dose #1
Do
se #2
HUMAN PAPILLOMA VIRUS (HPV)
Dose #1
Do
se #2
Do
se #3
POLIO
Dose #1
Dose #2
Dose #3
Dose #4
COVID-19 VACCINE
• All students are encouraged to remain up to date. List most
recent dose(s).
•
Must include the manufacturer’s name on the line next to
each dose or attach an official immunization record.
Page 3 of 4
Name (please print): UB Person #:
Section 4. Health Care Provider Signature REQUIRED to Certify Immunizations in Section 1, 2 and 3
Health Care Provider Address & Phone Number (Print/Stamp) Health Care Provider Name (Print/Stamp)
Date Health Care Provider Signature
Section 5. Physical Exam within past year
REQUIRED for 1
st
year Dental, International Dental Program(IDP), 3
rd
Year & ABS Nursing
Optional for all other students
Last First MI
Health Care Provider Name (Print/Stamp) Health Care Provider Address & Phone Number (Print/Stamp)
Health Care Provider Signature Date
Exam Findings:
To the best of my knowledge, this patient is free of any physical or mental impairment which is of potential risk to
patients/personnel, or which might interfere with the performance of their duties, including the habituation or addiction to
depressants, stimulants, narcotics, alcohol, and other drugs.
If the provider cannot certify, an explanation letter with medical provider signature must accompany this form.
Name (please print): UB Person #:
Last First MI
Page 4 of 4
PART A: CIRCLE
1.
Have you ever had a positive PPD, TB QuantiFERON, or T-SPOT test? YES NO
PART B:
1.
Are you currently enrolled (not intended) in a health-related program (Athletic Training, Communicative Disorders,
D
ental, Dietetic Intern, Exercise Science, Medicine, Med Tech/Bio Tech, Nuclear Med, Nursing, OT, Pharmacy, PT)? YES NO
2.
Were you born in, or have you lived, worked, or visited for more than one month in any of the following: Asia, Africa,
South America, Central America, or Eastern Europe?
Y
ES NO
a.
If yes, what country? How long?
3.
Do any of the following conditions or situations apply to you:
a. Do
you have a persistent cough (3 weeks or more), fever, night sweats, fatigue, loss of appetite, or weight loss?
YES
NO
b. H
ave you ever lived with or been in close contact to a person known or suspected of being sick with TB?
YES
NO
c. Ha
ve you ever lived, worked, or volunteered in any homeless shelter, prison/jail, hospital, or drug rehabilitation
unit, nursing home or residential healthcare facility?
YES
NO
Student Signature Date
*SKIP if NO to all the above questions
PART C:
REQUIRED IF YES TO ANY OF THE ABOVE QUESTIONS – TO BE COMPLETED BY YOUR MEDICAL PROVIDER
ATTENTION MEDICAL PROVIDER:
• If the student answered YES to any of the above questions, a TB test (PPD, T-SPOT, or TB QuantiFERON) is REQUIRED.
• TB test must be completed within one calendar year (unless history of positive TB test – see below).
• MUST ATTACH LAB REPORT IF T-SPOT OR TB QUANTIFERON IS COMPLETED
• If PPD result is 10mm or more, or T-SPOT or TB QuantiFERON is positive, a chest x-ray is REQUIRED.
• If the student has a history of a positive TB test, document date and result of the test and chest x-ray, as well as treatment information.
• It is not necessary for these students to repeat TB testing or the chest x-ray.
• History of BCG vaccination does not exclude the student from this requirement.
PPD
Date Placed:
PPD
Date Read:
Induration/
Measurement (in mm):
OR
QuantiFERON-TB Gold or
T-Spot Collected Date:
QFT-G or T-Spot Result (circle):
Positive Negative Equivocal
**MUST ATTACH LAB REPORT**
**Chest X-ray REQUIRED IF: PPD ≥ 10mm or Positive QuantiFERON-TB Gold/T-SPOT**
1.
Does the student have any of the following symptoms: cough with sputum production > 3 weeks, bloody sputum,
unintended weight loss > 10 pounds, drenching night sweats, unexplained fever, fatigue > 3 weeks?
YES
NO
2.
If negative chest x-ray and positive TB test, did the student complete a course of INH or other TB treatment?
YES
NO
a.
If yes, name & dose of medication
b.
Date range of treatment Number of months of treatment
Health Care Provider Signature Date
Health Care Provider Name (Print/Stamp) Health Care Provider Address & Phone Number (Print/Stamp)
Section 6. Tuberculosis Screening: Parts A & B REQUIRED for ALL Students
Part C REQUIRED if YES to any question in Parts A or B
Chest X-Ray
Result:
Chest X-Ray
Date:
