Summary: SECTION D: RREEQQUUIIRREEDD FFOORR IINNTTEERRNNAATTIIOONNAALL SSTTUUDDEENNTTSS. Complete sections A, B, D and E.
A PPD skin test performed in the United States is required. The skin test is offered at the University Health Center for a
minimal fee. In lieu of PPD placement in the US, documentation of a previous positive PPD (greater than 10mm) from your
country will be accepted and a recent chest x-ray (within 6 months) is required. Chest X-Ray report (in English) must be
reviewed by a Health Center Physician. Call 301.314.8184 for an appointment. Quantiferon® TB Gold or TSPOT® Test acceptable, lab
test documentation required.
SECTION E: PHYSICIAN SIGNATURE OR DOCUMENTATION REQUIRED FOR EVERYONE.
Physicians Complete Sections B through E.
PHYSICIAN SIGNATURE DATE
PHYSICIAN NAME (printed) PHONE NO.
PARENTAL PERMIT (FOR STUDENTS UNDER AGE 18) I give my permission for such diagnostic and therapeutic procedures as may be deemed necessary for my
son/daughter and agree to present information concerning his/her medical condition to other responsible university officials when deemed necessary.
For Health Center Use Only
MMR JJ MEN
SECTION C (RECOMMENDED): (Please record other immunizations you have received.)
Td J OR Tdap J (within 10 years) Date: Menomune J Menactra J Menveo J Date: