Academic Affiliations

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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*() - ext.   
Your Email Address* 

Student Information

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 Information

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