Varicella (Chicken Pox) History Form

Chicken pox (varicella) is now a vaccine-preventable disease.  Chicken pox can be a serious and even life threatening illness in certain individuals.  Several hospitals and clinical agencies with whom EMTS is affiliated with for clinical experience now require that we furnish documentation of a history of chicken pox immunity.  Varicella vaccination is now recommended for health care workers who have not had the chicken pox or who are susceptible to getting the chicken pox (unless there is a medical contraindication).  For these reasons we are now asking our EMS students to furnish us this information and recommending that those students who have a negative or uncertain history of chicken pox receive testing and vaccination if needed.

Select One I have had chicken pox. I am uncertain as to whether I have had the chicken pox. I have been immunized against chicken pox.

If you have had chicken pox or received the immunization for it enter the date here:

Hepatitis B -

Recommended to have series every 7 years or draw blood for a titer test to verify immunity from a previous series.

Shot Series:  Typically it is a 3 shot series followed by blood work to verify results.  Dose/shot 2 is give a minimum of 30 days after the first and the 3^rd is given a minimum of 2 months after the 2^nd.  2 months after the 3^rd dose blood work (titer) is taken to verify that you have Hepatitis antibodies and are considered protected.

Have you been diagnosed currently or in the past with Hepatitis B?   Select One No Yes    If no, have you started or completed the HepB Vaccine Series (These are the series of 3 shots)? Select One No Yes I do not know If yes, how many doses/shots have you received of the three?   Select One 1 shot 2 shots 3 shots None to date   What was the date of the last dose received? 

If you had blood drawn to perform a titer test a lab value is assigned.  It will read Hep B Surface Ab or HBV Surface Ab.  The measurement will be listed in mIU/mL.

What was the results of your Vaccine immune titer (blood work) results, if done?  Select One I have not had blood drawn for this test to the best of my kowledge Inconsistent with Immunity: Less than 9.0 mIU/mL Indeterminate: between 9.0 - 10.9 mIU/mL Consistent with Immunity: Greater than 10.9 mIU/mL  
Enter date in box if titer was preformed: 

EMTS Guideline:  Enrolled EMT-Basic students must complete a minimum of 2 HBV injections or a confirmed titer test prior to any clinincals being preformed.  Paramedic students must have all 3 HBV injections preformed prior to clinincals.  The Hep B Refusal Form is not an option for paramedic students.

OPTION: Hepatitis B Vaccine Refusal Form
I understand that as part of my clinical experiences as an EMS student, I may be exposed to blood or other potentially infectious material and that, as a result, I may be at risk of being infected by the Hepatitis B virus.  I understand that Hepatitis B is a severe and potentially life threatening illness and that taking the series of three vaccinations would significantly reduce my risk of being infected.  Nevertheless, I elect not to take the required series of vaccinations and assume responsibility for all arrangements, costs, and complications arising from not taking the Hepatitis B vaccine series.  I also understand that if the hospital or clinical agency where I have been assigned for my clinical(s) require students to be immunized for Hepatitis B, EMTS assumes no responsibility for reassigning me to another clinical agency and therefore I will not be able to take the required course.

OPTION: Waiver Form for Incomplete Hepatitis B Vaccine Series
I have started, but not completed the Hepatitis B Vaccine Series.  I understand that as a part of my clinical experiences as a student at EMTS, I may be exposed to blood or other potentially infectious materials and therefore may be at risk of being infected by the Hepatitis B virus.  I understand that this waiver is valid only until the date that my series is complete.  I agree to provide EMTS with immunization verification immediately upon completion of the series.

TB PPD Skin Test

Tuberculosis is a common and deadly infectious disease that is caused by myocobacteria.  TB most commonly affects the lungs but can also affect the central nervous system,, lymphatic system, circulatory system, bones and joints.  An injection is given in the skin followed by a reading taken 48 to 72 hours later.

Have you had a TB skin test within the last 12 months? Select One No Yes I do not know   If yes, what was the last date of your TB test: What was the TB results?  Select One Positive for TB Negative for TB

Or

You can have a chest x-ray performed:
Chest X-ray good for 2 years: Date taken: What where the results of the chest X-Ray?  Select One Did not need a chest X-ray Positive for TB Negative for TB

EMTS does offer TB (PPD)  testing in class for $15 which includes the reading of the test 48 to 72 hours after it was given.

MMR – Mumps, Measles, and Rubella

MMR vaccine is a toddler and/or teenager-adult shot given.  CDC suggests that you have:

1. Both (2 shots at different times) your childhood Measles, Mumps, Rubella (MMR) immunizations (commonly completed by age 4yrs)

2. If not sure on childhood status one adolescent/adult MMR doses should have been administered.

If you were born before Jan 1, 1957:
Have you had Measles?  N/A Yes No Unknown
Have you had Rubella?   N/A Yes No Unknown
Have you had Mumps?   N/A Yes No Unknown
If no history of having these diseases what was the date of an MMR vaccine:  Date:

If born after Jan 1, 1957:
Have you been given Measles, Mumps, or Rubella vaccines as a child (2 separate doses prior to around 4yrs of age)?   N/A Yes No Unknown
Enter year given shot 1: 
Enter year given shot 2: 

Enter your current age in years:

Have you had at least 1 MMR vaccine?  N/A Not needed. I had 2 childhood MMR shots. Yes. I have had an adult MMR shot. No Unknown
If given an adult MMR dose what was the date (typically given when a teenager ((9 thru 13 y/o)) but can be at any age):  

*If uncertain on childhood shots you should have at least 1 doses of MMR if born after 1957 and over 21 years of age.

Tetanus/Diphtheria (Td)

Tetanus, also known as lockjaw, is a rare, serious, and preventable disease that affects the body's muscles and nerves. It often arises from a skin wound that becomes contaminated by the bacterium Clostridium tetani, which is often found in soil. It is not contagious.

Tetanus/Diphtheria (Td) or Tdap vaccine within the last 10 years? Date:

Influenza

All healthcare workers should receive a flu shot.  Dependent upon flu season risk and clinical sites.  At this time the standard seasonal flu shot is required at clinical sites.  Please provide documentation of receiving this shot to Zoe in the office.

Date of last flu shot?