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Academic Affiliations

UMMC Affiliated Program Audit

Affiliated School:* 
Affiliated Program* 
Affiliated Program Coordinator* 
Affiliated Program Coordinator's Phone Number:* 
Affiliated Program Coordinator's Email Address* 
Name of Affiliated Program Representative Completing this Form* 
Your Phone Number*() - x   
Your Email Address* 


Directions: The name(s) of student(s) whom your program has placed at UMMC for affiliated student learning have been provided. Please upload the appropriate documentation for each student to each item below. If one document includes information for more than one health requirement, please upload the document to each applicable item.



Student's Legal First Name*Student's Legal Last Name*Student's Last Four of SSN*
   

Please attach the documentation for the student listed above for the following UMMC requirements:

TB skin test or blood test or chest x-ray (if previously positive) within the past year* 
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
Influenza vaccine during influenza season (or have on file an approved religious or medical exemption request)
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
2 MMR vaccines (or positive measles, rubella and mumps titers)* 
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
2 Varicella vaccines (or a positive titer or history of disease based on physician diagnosis)* 
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
3 Hepatitis vaccines (or positive hepatitis B antibody titer or have on file a declination statement)* 
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
Tdap vaccine (tetanus, diphtheria and acellular pertussis) within 10 years* 
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf


Student's Legal First NameStudent's Legal Last NameStudent's Last Four of SSN

Please attach the documentation for the student listed above for the following UMMC requirements:

TB skin test or blood test or chest x-ray (if previously positive) within the past year
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
Influenza vaccine during influenza season (or have on file an approved religious or medical exemption request)
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
2 MMR vaccines (or positive measles, rubella and mumps titers)
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
2 Varicella vaccines (or a positive titer or history of disease based on physician diagnosis)
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
3 Hepatitis vaccines (or positive hepatitis B antibody titer or have on file a declination statement)
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf
Tdap vaccine (tetanus, diphtheria and acellular pertussis) within 10 years
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf