WEST VIRGINIA UNIVERSITY SCHOOL OF MEDICINE
CHARLESTON DIVISION
AND
CHARLESTON AREA MEDICAL CENTER, INC.

MEDICAL STUDENT
SUMMER SHADOWING PROGRAM

STUDENT HEALTH STATUS FORM


STUDENT’S NAME: ________________________________________

CERTIFYING PHYSICIAN’S STATEMENT:

I am aware that the above-named student has been accepted as a student in the West Virginia University and CAMC Shadowing Program. Within the past year, I have performed a physical examination and thorough evaluation of this student’s health status. In my judgment, the student appears to be free of any physical or mental health impairment which would interfere with the performance of his/her duties or which would pose a potential risk to either patients, hospital or medical school personnel. There is no evidence to suggest habituation or addiction to depressants, stimulants, narcotics, alcohol, or any other substance which may alter behavior.

For each of the following, please indicate whether or not the student has documented immunity and, if not immune, the dates on which vaccination has been administered. Indicate if student not vaccinated for the following reasons: E = exemption (religious beliefs); D = Declination; C = contraindication; SRI = Self reported illness

MEASLES/MUMPS/RUBELLA: Immune_______ Not immune_______ Vaccination Date_______

TITER __________________________________ (Result and Actual Value)

TETANUS-DIPHTHERIA: Dates of Initial Series___________________________________________

(Must have been within last 10 years) Most Recent Td________________________________________________

HEPATITIS B: Immune_______ Not immune_______ Vaccination Date_______

TITER_____________

HEPATITIS SERIES: Dates of Immunization: _______ #1 ________ #2 ________ #3

VARICELLA (CHICKENPOX): Immune_______ Not immune_______ Vaccination Date_______

TITER__________________________________ (Result and Actual Value)

PPD (Mantoux) (Tine not accepted) Date_______________ (MUST have been within past 12 months)

NEGATIVE__________________ POSITIVE______________(If positive, please indicate the date and results of the most recent chest x-ray and whether or not any therapy has been initiated):__________________________________________

__________________________________________________________

POLIO (Dates of Vaccine) Immune_______ Not immune_______ Vaccination Date_______

Other tests/vaccinations may be required by WVU/CAMC in its sole discretion at any time. Based on the screening and laboratory information, additional laboratory or radiological studies may be ordered for any student.

PHYSICIAN’S NAME (Please Print) __________________________________________________________

PHYSICIAN’S SIGNATURE________________________________________________________________

Please send completed form to:

Robert C. Byrd Health Sciences Center of WVU-Charleston Division
Office of Student Services, Charissa Davis
3110 MacCorkle Avenue, S.E. Charleston WV 25304
Phone: (304) 347-1293 Fax: 347-1251