Get Immunization History - Rosalind Franklin University Health System

This guide provides detailed instructions for filling out the Immunization History form required by Rosalind Franklin University Health System for clinical program enrollment. Follow these steps to ensure that your immunization records are accurately submitted.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information, including your name, date of birth, address, and program of enrollment. Make sure to provide the correct address details, including city, state, and ZIP code.
3. For the Infectious Disease History section, carefully read each disease listed. Check 'Yes' if you have had the disease or 'No' if you have not. Be sure to check both sections — for Rubeola, Mumps, and Rubella, and for Varicella and Tuberculosis.
4. In the Immunization History section, provide the dates of your immunizations and any IgG antibody titer results. Ensure that you submit copies of laboratory reports if required. Include dates for Tetanus, Mumps, Rubella, Rubeola, Varicella, Hepatitis A and B vaccines if applicable.
5. For the tuberculosis test results, fill in the dates for the PPD placements and readings. Indicate the induration in millimeters and circle the appropriate result (positive or negative). If a Quantiferon Gold test was conducted, record the result as necessary.
6. Complete the declaration of accuracy by signing the form. The healthcare provider will also need to sign and print their name with the date of signing.
7. After filling out all sections, review the form to ensure all information is complete and accurate. Then, save your changes, and download, print, or share the form as needed.

Complete your Immunization History online today to ensure a smooth enrollment process.