Immunization, Health History

and Physical Examination

Information

Dear Student:

A complete health history, physical examination, serum blood titers, Tuberculosis

clearance, immunization records (since childhood), COVID-19 vaccination record,
a Tdap vaccine and completion of all the attached forms is required prior to
registration at Western University of Health Sciences (WesternU).

WesternU requires full vaccination against COVID-19. If you have received

the COVID-19 vaccination, please provide a copy of the shot record in your
health packet. If you want to know more about COVID-19 vaccinations,
please
visit www.cdc.gov/coronavirus/vaccines, or discuss it with your personal
healthcare provider or your pharmacist.

NOTE: Please note that all colleges at WesternU have the same final submission deadline
of June 1st for all documents, including those required for health clearance.
The Student Health Office (SHO) highly recommends you submit your fully completed health
clearance documents as early as the month of March.
If you wait until the deadline to submit all of your health clearance documents to the SHO,
it can take at least 10-business days or longer to process your documents and to release the
hold that would prevent you from registering for your classes.
All documents are processed on a first-come-first-served basis.
You should only need to contact the SHO if you have not received an email or phone call
from us 10 business days or more after you have submitted all of your health clearance
documents.
Every document you submit must contain your name and
WesternU Student ID number.

Return All Completed SHO Forms To:

[email protected]
For questions, call: 909-706-3830
1
 Immunization, Health History
and Physical Examination
Information

HEALTH CLEARANCE “TO DO” LIST

Take the Health Clearance Packet and forms with you every time you visit your Healthcare Provider

1st appointment with your Healthcare Provider (can only be: MD/DO/NP/PA):
 Physical Examination (Form C): make sure form is completely filled out and signed by your Healthcare Provider.
 Order the following serum blood titers (any quantitative result must have reference ranges to
be accepted.

NOTE: only a QUANTITATIVE result will Can be either Qualitative or Quantitative

be accepted
[if QN, must include reference range numbers]
Hepatitis B (HBsAb, QN) Varicella (Varicella AB, IgG), Measles (Measles
AB, IgG, EIA) Mumps Mumps AB, IgG), Rubella
(MMR AB, IgG)
• A Tdap vaccine obtained within the last 10 years. A TD or DTap will not be accepted.
• Obtain/complete COVID-19 vaccination
Tuberculosis Clearance must be one of the following:
• 1st TB skin test administered (must be read after 48 to 72 hours after administration).
IGRA blood test [preferred if you have had a BCG vaccine in the past], e.g., Quantiferon or T-spot Test (valid at
WesternU for 4 years).
• Chest x-ray: required only if you have history of positive TB skin test or if your IGRA test is positive.
2nd appointment with your Healthcare Provider:
• Review titer results and obtain copy of all actual lab results and, if performed, Chest X-ray report.
• Receive immunizations, if indicated, and provide documentation of administration.
Tuberculosis Clearance:
• TB skin test: results are read and must be a number, e.g., 0 mm, the words “negative” or “positive” will not
be accepted.
• IGRA: (e.g., Quantiferon or T-spot) test lab report and completed TB Symptoms Health
Screening Checklist form, signed/dated by your Healthcare Provider.
• Chest x-ray: radiology report and completed TB Symptoms Health Screening Checklist form, signed/dated
by your Healthcare Provider. Please provide documentation of positive skin test or IGRA test
resul ts along with the report for the chest x-ray.
Obtain copies of all your immunization records since childhood from your healthcare provider’s office, high
school, or previous university.
Gather all your health clearance documents and ONLY the following are to be sent to Student Health:
 Forms A through D, completed, signed, and dated
 Copies of all titers and other required lab results
 Copies of all immunization records since childhood, including COVID-19 vaccination card
 TB clearance as described above
 Fill out, date, and sign the following forms:
• Annual Health Requirements Attestation
• Authorization for Release of Communicable Disease Clearance Information to Clinical Rotation Sites
• Authorization for Release of Student Health Clearance Documents.

Send all your documents at one time via email (PDF or JPEG format).
Do not send your forms a few pages at a time as they can be misplaced.
Do not depend on your healthcare provider’s office sending all your forms to us.
2
 Form A: Student Information
This section to be completed by the student.
Please use ink and print clearly.

Name Date of Birth

Last First Middle Sex (circle): Male Female

WesternU Student ID# @ Anticipated Year of Graduation: 20

Program (indicate the college you will be entering))

COMP-DO: California College of Health Sciences: College of Health Sciences: PA College of Graduate Nursing
PT – CA PT - OR
COMP-DO: Oregon
College of Pharmacy College of Veterinary Medicine College of Podiatric Medicine
College of College of Biomedical
College of Optometry College of Biomedical Sciences MSBS
Sciences MSMS
Dentistry

Current Address:
Street Address

City State Zip/Province Code

Telephone Number: WesternU Email: @westernu.edu

Person to notify in case of an emergency/accident:

Name: Relationship:

Last First Middle Initial

Address:
Street Address

City State/Country Zip/Province Code

Telephone: Cell:
(Please include country code if telephone numbers are outside of the United States)

Email:

Signature of Student / Date Signed

 Form B: Health History
This section to be completed by the student.
Please use ink and print clearly.

Name: WesternU Student ID# @

Allergies (drugs/food):

Medications currently taking:

Place a check mark if you currently or have ever had any of the following:
HEAD GASTROINTESTINAL BLOOD DISORDER
Major dental problems Abdominal pain Anemia
Dizziness or Fainting Recent changes in appetite Rheumatic fever
Encephalitis Recent changes of bowel habits Sickle cell
EYES Recent constipation Lymphoma
Eye trouble Frequent diarrhea Other
Wear glasses Digestive disorder
Wear Contact Lenses Difficulty swallowing MENTAL HEALTH
EARS/NOSE/THROAT Recurrent emesis (vomiting) Frequent nightmares
Allergies Gastric or duodenal ulcer Trouble concentrating
Ear trouble Hemorrhoids/Rectal fissures Cry often
Hearing problem Other ano-rectal disorder Feeling of depression
Frequent nosebleeds Hernia Tendency to worry
Hay fever Intestinal worms Memory loss
Frequent sore throat Jaundice Mental health disorder
ENDOCRINE Black bowel movements Feelings of loneliness
Hypothyroid Vomiting blood Considerable nervousness
Hyperthyroid Intestinal inflammation Difficulty sleeping
Diabetes mellitus Gall bladder disease Considered suicide
CHEST/HEART/LUNGS/VASCULAR Hepatitis Lose temper often
Breast disease or masses GENITOURINARY Require use of sleeping aids
Chest pain/pressure Urine contains (circle): Blood Albumin Sugar Other
Heart disease/murmur Kidney disease ADDITIONAL MEDICAL HISTORY
High blood pressure Bladder disease Cancer
Rapid or irregular pulse Painful urination Unusual fatigue
Varicose veins Frequent urination Frequent colds
Asthma Genital disorder Serious illness
Chronic cough Prostate gland disorder Sexual problems
Emphysema Frequent urinary tract infections Skin disorders/infections
Lung disease Other Unexplained weight gain or loss
Night sweats FEMALES ONLY Other
Pleurisy Abnormal pap smear SURGICAL HISTORY
Wheezing Ovarian cysts Appendectomy
Shortness of breath Pelvic inflammatory disease (PID) Gall bladder
Coughing up blood Pregnancy: G P Pelvic surgery
INFECTIOUS DISEASE Painful menses (dysmenorrhea) Cesarean section
Ambiasis Fibrocystic disease Tonsillectomy
Chicken pox Other Other
Coccidiomycosis (Valley Fever)
Encephalitis SOCIAL HISTORY
Hepatitis Smoke tobacco
Histoplasmosis MUSCULOSKELETAL Alcohol use
Intestinal Parasitic infection Arthritis Other
Malaria Chronic muscle pain
Measles Spine problem, e.g., disc or vertebrae Please explain any areas that you checked or
Meningitis Swollen of painful joints/extremities may not be
Mononucleosis Bone infection
Mumps Amputation
Prior BCG vaccine
Prior positive PPD
Rheumatic fever NEUROLOGICAL
Rubella Speech defect
Scarlet fever Cluster headache
Sexually transmitted disease Migraine headaches
Tuberculosis Paralysis, tremors, muscle weakness
Neuralgia or numbness
Seizures
 Form C-1: Physical Examination
This section to be completed by the DO, MD, NP, or PA only.

Name: WesternU Student ID#:

Date of Exam: Ht: Wt:

BP: / Pulse: Resp: Vision: R / 20 L / 20 Corrected / Uncorrected (circle)

Detailed Description of ABNORMAL Findings

GENERAL:
Posture, gait, speech, appearance

HEAD:
Hair, symmetry, tenderness

EYES:
Lids, sclera, conjunctiva, muscles, cornea, pupils, fundi, peripheral fields

EARS:
Pinna, canal, drum, hearing

NOSE:
Septum, obstruction, mucosa

MOUTH/THROAT:
Breath, lips, teeth, tongue, mucosa, pharynx, tonsils

NECK:
Thyroid, motion, trachea, veins

LYMPHATICS:
Cervical, supraclavicular, axillary, inguinal

CHEST/LUNGS:
Symmetric, percussion, excursion, breath sounds

CARDIOVASCULAR:
PMI, Rate, Rhythm, Sound, Murmur, Neck Bruits, upper ext. pulses, lower
ext. pulses, leg veins, edema, abdominal bruit

ABDOMEN:
Tenderness, organs, hernia, masses, sounds, scars

MUSCULOSKELETAL:
Back, upper extremities, lower extremities

SKIN:
Birthmarks, rashes, scars, texture

NEUROLOGIC:
DTRs: Biceps, Triceps, Patella, Ankle, Romberg, Babinski, Cranial Nerves,
sensory, coordination, tremor, vibratory

MENTALSTATUS:
ALOC x 3, affect, judgment, cognition, memory, abstraction,
hallucination/delusions

Breasts, Rectal, Gyn and male GU are not required to be examined

The physical exam can be no more than 6 months old from date you will begin classes.
 Form C-2: Physical Examination
This section to be completed by a DO, MD, NP, or PA only.

Name WesternU Student ID#:

Last First Middle

Other Findings:
Are there any restrictions on physical activity? No Yes If yes, please explain:

Are there any recommendations for continued medical care/follow up? No Yes If yes, please explain:

Tdap vaccination (tetanus/diphtheria/acellular pertussis) date :

NOTE: A TD and/or Dtap will NOT be accepted.

Immunization records
Student must submit immunization records beginning in childhood and COVID-19 vaccination card.

HealthcareClearance:
Tuberculosis provider name (printed/stamped):
1. No history of positive TB skin test or IGRA must submit one of the following:
Signature: Date:
TB PPD skin test. If you have not had 2 separate TB (PPD) skin tests completed within the past year, then 2 separate TB
(PPD) skin
Address tests at leastprovider:
of Healthcare
10 days apart from the 1st PPD being administered is required.
Date 1st PPD Placed: Date 1st PPD Read:
Results of 1st PPD: Millimeters of Induration (the words “negative” or “positive” are unacceptable)
Phone number (please include country code if outside of USA) ___________________________________________
Date 2nd PPD Placed: Date 2nd PPD Read:
Results of 2nd PPD: Millimeters of Induration (the words “negative” or “positive” are unacceptable)

Having a history of receiving the BCG vaccine alone is not acceptable as a positive PPD history unless a skin test has been given and
the result was 10mm or greater.

IGRA (e.g., Quantiferon or T-spot) Date: this is the preferred test if history of receiving BCG
vaccine. Must not be more than 6 months from the first day of matriculation. Must submit IGRA lab. results and a completed TB
Symptoms Health Screening checklist. (Note: This test is valid for 4 years at WesternU)

2. Positive history of TB skin test and/or IGRA must submit:

Chest x-ray/radiology Date: must not be more than 6 months from the first day of
matriculation. Must submit Radiology report, completed TB Symptoms Health Screening checklist, and provide documentation of previous
positive TB skin test and/or IGRA results. (Note: This test is valid for 4 years at WesternU)
 Form D: Immunization/Titer Results
Titers cannot be more than 1 year-old and copies of all lab reports must be
Name WesternU Student ID#:

Serum blood titers are NOT the same as vaccinations/immunizations.

1. Hepatitis B Surf Ab, Quantitative QN] Only a QUANTITATIVE titer result will be accepted.
Titer Date: Titer Results:

Note: If Negative, Start Hepatitis B Series: date #1 #2 #3

Day 0 30 Days After #1 6 Months after #1

**NOTE: If you need to be revaccinated, you can go ahead and submit your documents as soon as you have received the 1 st
Hepatitis B vaccine. If you have received two complete Hepatitis B series’ and the titer still shows no immunity, then you
must provide proof of two complete vaccination series before you can be declared a Hepatitis B non-converter. Once
declared a non-converter, you will not be required to receive any more Hepatitis B vaccines.
Hepatitis B Carrier **Known Hepatitis B carriers are required to have the additional blood tests listed
below and the results must be included in the health clearance documents you submit: Date: Hepatitis B
Surface Ag, Hepatitis B core Ab, and Hepatitis Be Ag

2. Measles, Mumps and Rubella (MMR)

a. Measles (Rubeola) AB, IgG, EIA Titer date: Titer Results:
Date of Immunization #1: Date of Immunization #2:
b. Mumps Antibodies, IgG Titer date: Titer Results:
Date of Immunization #1: Date of Immunization #2:
c. Rubella Antibodies, IgG Titer date: Titer Results:
Date of Immunization #1: Date of Immunization #2:

 Titer positive/reactive, no additional vaccine necessary.

 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received
2 MMR vaccines, then 1 MMR vaccine is recommended.
 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received
1 MMR vaccine, then 1 MMR vaccine is required.
 Titer negative/non-reactive/inconclusive/equivocal, and you do not have a documentation showing you
received 2 MMR vaccines, then 2 MMR vaccines required at least 30 days apart.

3. Varicella IgG AB Titer date: Titer Results:

Date of Immunization #1: Date of Immunization #2:

 Titer positive/reactive, no additional vaccine necessary.

 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received
2 Varicella vaccines, then 1 Varicella vaccine is recommended.
 Titer negative/non-reactive/inconclusive/equivocal, and you have a documentation showing you received
1 Varicella vaccine, then 1 Varicella vaccine is required.
 Titer negative/non-reactive/inconclusive/equivocal, and you do not have a documentation showing you
received 2 Varicella vaccines, then 2 Varicella vaccines required at least 30 days apart.
 TB Symptoms Health Screening Checklist
This form only applies to those required to have a
chest x-ray or have had an IGRA (Quantiferon) test.
COMP-CA COMP-OR Dental MSMS MSBS Nursing Optometry PT-CA PT-OR PA Pharm Podiatry Vet Med

Student/Employee ID # @ Grad. Year: 20

Name DOB Sex: Male Female

Address Phone:
City/State/Zip

Date of last PPD PPD Results MM

Date of IGRA (e.g., Quantiferon/T-Spot) test: Results): Negative Positive

Date of Last Chest X-Ray: Results: Positive for TB Negative for TB

1. Have you ever been told you have active tuberculosis? Yes No

2. Have you ever taken Isoniazid (INH) or Rifampin (RIF)? Yes No

3. Date and duration of medication regime (months)

4. Have you ever had BCG Vaccination? Yes No If yes, when?

(If you have had the BCG vaccination, it is preferred that you obtain an IGRA [e.g., Quantiferon or T-spot test])

5. During the past year have you noticed (circle your answer):
Yes No Unexplained weight loss?
Yes No Decrease in your appetite?
Yes No Cough not associated with cold or flu?
Yes No Increase in AMOUNT of Sputum?
Yes No Change in COLOR of Sputum?
Yes No Change in CONSISTENCY of Sputum?
Yes No Blood Streaked Sputum?
Yes No Night sweats?
Yes No Unexplained low grade fever?
Yes No Unusual tiredness or fatigue?
Yes No Swelling of lymph nodes?
Yes No Have you had contact with a family member or partner who has been diagnosed with tuberculosis?
Yes No Have you or a member of your family been exposed to someone who is immune compromised?

Explain any “Yes” answers above:

List any on-going medical problem

Signature of Person Completing this form Date

o Plan of care, if indicated:

Signature of Reviewer:Date

No further action needed Chest X-Ray Requested Further Evaluation Needed

Must be reviewed by licensed healthcare provider if any “yes” answers

 Annual Health Requirements Attestation

I, WesternU ID#: @ _ understand that:

(Printed Name of Student)

Tuberculosis Clearance
It is my responsibility to remember to renew my Tuberculosis clearance each year
before it will expire.
 If my PPD skin test does expire, I know I will be required to complete 2
separate PPD skin tests, 10-days apart in order to be in compliance with the TB
clearance protocol.
 I understand that if my TB clearance was completed by chest x-ray or IGRA
serum blood test, I must complete a TB symptoms checklist and submit it to the
Student Health Office on a yearly basis.

Annual Influenza Vaccination

I must obtain and submit proof of receiving the yearly Influenza vaccination no later than
November 30th of each year to the Student Health Office.
 I am also aware the only exception to this mandatory vaccination requirement is if there is a
medical contraindication and that a healthcare provider’s dated and signed note attesting to
this fact must be provided to the Student Health Office before the date noted above.

Hold Placed on Student Account

I am aware I will not be notified of a hold placed on my student account if my health clearance
requirements are not up to date.
 I also understand the hold will not be removed until I have submitted any outstanding
items to the Student Health Office.
 I understand that this means I will not be able to register for classes or obtain financial
aid until the hold is cleared.

By signing this attestation, I certify that I am fully aware of these health clearance
requirements and agree to comply with same.

Student Signature: Date:

 Authorization for Release of Communicable Disease
Clearance Information to Clinical Rotation Sites

I, , WesternU ID#: @
(Printed Name of Student)

hereby authorize:
Western University of Health
Sciences Student Health
Office
100 W. Second Street, Room 219
Pomona CA, 91766-1700

to release to the extent permitted by law, the following medical information that Western
University of Health Sciences (WesternU) now has in its possession, or that it may create or
receive from any third party in the future: Immunization information (including titer results);
Tuberculosis clearance; History and Physical Exam report to any of the clinical rotation site(s)
that I am or will be assigned to as a student of WesternU and any additional health clearance
requirements that a clinical rotation site may require. I understand that this information must
be provided, if requested, in order to prove to a clinical rotation site that I meet all
communicable disease clearance requirements as required. I also understand that if I do not
allow this information to be provided to the various clinical rotation sites, a clinical rotation
site can refuse to allow me to rotate through its facility. I am also acknowledging that if I
cannot complete the clinical rotations required for my degree and/or licensure because of my
refusal to authorize the release of my communicable disease clearance information to the
clinical rotation sites, I agree to hold WesternU harmless to the extent permitted by law. I also
am aware that this Authorization will remain in effect for the duration of my time as a student
at WesternU and will expire on the date of my graduation from the University.

By signing this Authorization, I agree with all the provisions stated in this Authorization for
the release of the specified information and continued health clearance requirements.

Student Signature Date

 100 W. Second Street, Room 219
Pomona, CA 91766-1700
Tel: (909) 706-3830  Fax: (909) 706-3785

AUTHORIZATION FOR RELEASE OF STUDENT HEALTH CLEARANCE DOCUMENTS

College: COMP-CA COMP-OR Dental MSMS MSBS Nursing Optometry PA Pharmacy Podiatry PT Vet Med

Student ID # @ Grad Year 20

Please Print

Name DOB Sex: Male Female

Address Phone:

City/State/Zip

I hereby request and authorize that the Student-Employee Health Office email my Health Clearance Records

to my WesternU email address of:@westernu.edu or to

The Health Clearance Records I am authorizing for release include:

*Immunizations/Titers *Tuberculosis Clearance Documents *History and Physical Exam

Other:
NOTE: Unless lined out, those with an * will be sent to the email address you indicate

A handwritten signature is required in order to activate this request.

Note: A photocopy or electronic scan of this document shall be as valid as an original.

Student Signature Date

This Authorization is valid until otherwise notified in writing.

 Health Clearance FAQs

Please carefully read the details below regarding the documentation you must provide in order to register for classes.

1. History and physical exam: must be within six (6) months of matriculation (first day of beginning your classes at
WesternU).

2. Serum blood titer reports: must be drawn within one (1) year of matriculation and show you are immune against measles,
mumps, rubella, varicella and Hepatitis B. Immunization records and/or “had the disease” alone will not be accepted for
these diseases. You must submit serum titer lab results that include reference ranges, along with your immunization records.
These records must show, at minimum, your name, the name of the vaccine and the date of administration.
a.
Your healthcare provider MUST ORDER THE FOLLOWING titers to meet this admission requirement:
1. Hepatitis B Surf AB QN (only Quantitative results will be accepted, must include reference range numbers)

The lab results for the following can be either Qualitative (QL) or Quantitative (QN).
2. Measles AB IGG, EIA
3. Rubella Antibodies, IgG
4. Mumps Antibodies, IgG
5. Varicella IgG AB
6. Rabies titer (applies to Veterinary Medicine students only): must be a Rapid Fluorescent Focus Inhibition Test
(known as a RFFIT) and ONLY if the Rabies vaccine series of three (3) shots were received/completed two (2) or years before
you start your classes here at WesternU. Please note the RFFIT is the only rabies titer we will accept.
b.
Based upon your health history or current health status, if a particular immunization is medically (temporarily/permanently)
contraindicated, a signed letter from your licensed healthcare provider attesting to this contraindication will be acceptable.
However, you will still be responsible for obtaining the immunization clearance as soon as your temporary health issue is
resolved. You will not be cleared to start any clinical rotations without this clearance.

3. Hepatitis B vaccine series: if you have initiated the Hepatitis B vaccination series prior to starting classes, but have not yet
completed the series, registration for your first semester of classes will not be delayed, if you submit documentation showing
you have started the Hepatitis B vaccination series. However, you will need to submit proof of receiving the remaining vaccine(s)
as soon as they have been received. You must also provide a Hepatitis B Surf ABQN titer, that was drawn at least 30-days after
your last Hepatitis B vaccine.

4. Tetanus/Diphtheria/Acellular Pertussis (Tdap) booster: we require one documented Tdap booster within the last
10 years. An immunization record is required for this vaccination.

5. COVID-19 vaccination: you must provide proof of receiving/completing the vaccination series and be cleared by your
first day of classes). Medical exemption, religious exception and pregnancy deferrals will be considered.

6. Tuberculosis (TB) clearance: YEARLY REQUIREMENT NOTE: If you need to have the 2-step (meaning 2 separate) PPD
skin test, they must be at least 10 days apart or they will not be accepted. If you are on the Pomona campus, you can obtain
your 2nd PPD skin test during the first week of classes at the Patient Care Center Pharmacy on the east end of campus. It is your
responsibility to renew your yearly TB clearance and submit it to Student Health before it expires. The only acceptable TB
clearance is one of the following:
a.
Tuberculin Skin Test (commonly known as a PPD): PPD results must be read 48- to 72-hours after administration and
the results must indicate millimeters of induration and not simply “negative” or “positive.” The form must be dated and
signed by a licensed healthcare provider or it will not be accepted.
b.
IGRA lab test: reports cannot be more than 6 months from date of starting classes and must indicate qualitative results.
This blood test is valid at WesternU for four (4) years however students must also submit a completed, signed and
dated TB Symptoms Health Screening checklist form on a yearly basis to the Student Health Office. This test is
preferred if you have a history of having received a BCG vaccine.
c.
Chest x-ray: If you have a prior history of latent TB infection (LTBI) as determined through a tuberculin skin test (PPD) or a
blood test (IGRA), a licensed healthcare provider must provide a signed, written report that shows you do not have active TB
disease. If a chest x-ray was required for TB clearance, a copy of the actual radiology report and a completed TB Symptoms
Health Screening checklist form must accompany your health clearance documents. Please note that the chest x-ray cannot have
been taken more than 6-months prior to the start of your start of your classes.

Prior history of active pulmonary TB: a licensed physician must provide a signed, written report that must show you have
completed, or are in the process of completing, all required therapy. The report must include the name of the medications, dosages,
 frequency of administration, andtotal doses received. If you have completed the therapy, the report must state this fact, including
the date the treatment was completed. If your treatment is still in process, the report must state when it is expected to be completed.
Additionally, a chest x-ray report is required for admission clearance. You must provide a copy of the actual radiology report and it
cannot be more than 6-months old if: 1) you have completed the treatment and/or, 2) from the day you start class.

History of BCG vaccination: prior BCG vaccination is NOT a contraindication to either PPD or IGRA. IGRA test is preferred if
you have received a BCG vaccine in the past. In this setting, interpretation of the results of screening tests for TB infection will
take into account each of the following:
1) the length of time between past BCG vaccination and the screening test; and 2) the risk of infection with
Mycobacteriumtuberculosis.

7. Influenza vaccination: YEARLY REQUIREMENT—all students must receive the annual influenza vaccination every fall.
Documentation of receipt of this vaccination is required and must be submitted to the Student Health Office no later than the
November 30th each year or a hold will be placed on your account. If you have a medical contraindication to receiving the
yearly influenza vaccine, a note from your healthcare provider on their letterhead, that is also signed/dated is required. An
email “letter” or “note” is not accepted.

Veterinary Students ONLY

8. Rabies vaccination: Students enrolling in the DVM program must provide all of the above documentation as well as show
proof of having received the pre-exposure series of rabies immunization or agree to complete the rabies vaccinations as part
of the University matriculation process no later than September 30th of the current year.
a.
A pre-exposure series involves the administration of three (3) intramuscular doses of the vaccine given on days 0, 7 and 21
or 28.
b.
You can begin receiving your rabies vaccination series now or during orientation week on campus at the Patient Care
Center Pharmacy. A fee is charged for each of the vaccines you have to receive. For pricing, please call 909-706-3730.
c.
Students who have previously received the Rabies vaccine series may be excused from being re-vaccinated by providing
official documentation from their healthcare provider stating the dates they received all 3 rabies vaccines. The serum
RFFIT titer (which measures level of immunity to rabies) must be done two years after completing a rabies vaccines series.
If the vaccines were completed more than 2 years ago, you will need to obtain a RFFIT serum titer. The titer results must
also be included in the documentation you will be sending in.

KEY POINTS
 No further health clearance reminders will be sent to you.
 It is your responsibility to keep track of items you are required to submit to the
Student Health Office.
 If you fail to submit required documents when they are due, a hold will be placed
on your account. This means you will not be able to register for classes, receive
financial aid payments, or obtain transcripts.

All records/documents submitted must be either originals or clean, legible, and clear copies. They must also contain your name, WesternU
Student ID #, the college/program in which you will be enrolled, and your anticipated graduation year must be clearly written on each
document, e.g., John Smith, @0012345678, CVM 2026.

If you have medical questions on any of the above, please consult with your personal healthcare provider.

If you have any additional question regarding the health clearance requirements, you may direct them to the Student Health Office at
909-706-3830. You can also email us at: [email protected]
 Immunizations, Tuberculosis Clearance & Titers

Q—Why do I need to submit my immunization records and serum titers?

A—Many clinical rotation sites that our student’s rotate through require copies of both your immunization records and serum titer
results. When you are preparing to start at a clinical rotation site that requires this information, you will just need to contact the Student
Health Office. (If you are having trouble locating your immunization records, you may want to check with your high school/undergraduate
college/university Health Center to see if they have a copy of your vaccination history).

Q—If my healthcare provider writes a note stating the student “is up-to-date on all vaccines,” is this acceptable?
A—No. Documentation requirements for your health records must show the specific dates you received the vaccines. Health records may
be in the form of original vaccination records (or a clear copy) or a letter from the healthcare provider on their letterhead or printed
prescription (no emails allowed) stating the vaccine name and dates each was administered. The letter must be signed by the
healthcare provider. We will not accept school records, family member statements or baby book entries.

Q—If I get behind in a vaccination series (i.e., hepatitis B, MMR, or varicella), what should I do?
A—You will pick up where you left off and complete the vaccination series. For example, you received the first shot of the Hepatitis B vaccine
series, but you have not received the rest of the vaccine, your healthcare provider can determine what else may be needed. If you can show
you have started a vaccine series, you will be allowed to register for your first semester but until you provide proof you have completed
the series, you will not be allowed to register for any subsequent semesters/classes.

Q—If I received a vaccine dose earlier than the minimum interval recommended, is this acceptable?
A—No it is not. The dose of vaccine is invalid and must be re-administered after the minimum interval has been met. For example, the
hepatitis B minimum intervals are as follows: Dose 1 is administered. Dose 2 should be separated from dose 1 by at least one month (4
weeks or 28 days). Dose 3 should be separated from dose 2 by at least 2 months (8 weeks) AND from dose 1 by at least 4 months (16
weeks).
Q—Will vaccines interfere with my TB skin test (commonly known as a PPD) results?
A—Some vaccines may. For example, the MMR vaccine may interfere with PPD results (may have a false negative result in someone
who actually has an infection with TB) if the vaccine is administered within 4-weeks of the PPD. However, the MMR vaccine can be
administered at the same time and on the same day as the PPD. The hepatitis B, tetanus and rabies vaccines can be administered any
time without interfering with PPD results.

Q—How do I know if my 1st PPD will be accepted or counted?

A—If you have not had a PPD in more than one year, you are required to complete the 2-Step PPD process before your complete TB
clearance requirement has been met. The 2nd PPD must be administered at least 10-days from the 1st PPD being administered.

Q—If I received the TB skin test at WesternU, can I have a healthcare provider at a non-WesternU clinical rotation site read the TB
skin test results and document them?
A—If your clinical site is near a WesternU campus, then the answer is no. It must be read at WesternU and documentation must then be
provided to the Student Health Office located in the Anderson Tower on Garey Avenue and 2nd Street. However, if your clinical rotation
site is not near the campus, you can have the TB skin test read by the Employee/Occupational Health nurse at the clinical facility you are
rotating through. The results can be faxed to 909-706-3785 or scanned and emailed to [email protected]

Q—Can I submit an IGRA (e.g., Quantiferon or T-spot) blood test for TB clearance?
A—Yes, if you do not have a history of a positive Tb skin test. The test cannot be more than 6 months from your first day of
matriculation. This test is valid at the university for 4 years. However, you are still required to submit a completed TB Symptoms
Health Screening Checklist form on a yearly basis.

Q—Do I only have to complete a TB clearance on a yearly basis?

A—Not necessarily. Some clinical rotations sites have more stringent TB clearance requirements that you must comply with in order for
you to be permitted to go to that site.

Q—Do I need to get a PPD if I have a history of a positive PPD?

A—No. You are required to obtain a chest x-ray (x-ray cannot be more than 6 months old from your first day of starting classes at
WesternU) and complete the TB Symptoms Health Screening Checklist included in this packet. We do not need the actual chest x-ray
film; we only need the radiologist’s written report.
Q—I am healthy. Why should I be required to show that I have been immunized?
A—As members of the WesternU community, it is very important for all of us to be free from communicable diseases that can threaten
those around us. Many of these diseases are preventable with appropriate vaccination. Also, in order for you to participate in your
required clinical rotations, you must be able to show proof that you are not at risk for contracting a vaccine preventable communicable
disease.

Q—If I received my second Hepatitis B vaccine (Engerix-B or Recombivax) later than recommended after the first vaccine, how soon
after getting the second Hepatitis B vaccine can I receive the third and final Hepatitis B vaccine?
A—If you had the 2nd vaccine several months after the first one, you can receive your 3rd and final Hepatitis B vaccine 60-days after the 2nd
vaccine. A serum blood titer is still required 30-days after vaccine number three.

Q—If I have completed 2 full Hepatitis B series and my titer is still showing I do not have immunity, do I need to complete another
series?
A—No, because most likely you are a non-converter, however, you will need to provide us with the documentation showing that
you have completed 2 entire Hepatitis B vaccination series and a current Hepatitis B Surface Ab, QN titer.

Q—What is WesternU’s policy on COVID-19 vaccinations?

A—Please go to https://www.westernu.edu/media/health/pdfs/covid-19-vaccination-program-policy.pdf for current information

Titers
Q—What titers should I ask my physician/healthcare provider to order?
A—Hepatitis B, Surf AB QN; Measles AB IgG, EIA; Rubella Antibodies, IgG; Mumps Antibodies, IgG; Varicella IgG AB.
NOTE: the Hepatitis B titer results MUST be Quantitative and include the references ranges or we will not accept the test results.

Q—How do I read/interpret MMR / MMRV titer results?

A--
Titer Results Vaccination Action to take
Positive Completed both vaccines No further action needed
Negative or Equivocal Completed both vaccines Booster vaccine recommended
Negative or Equivocal Only 1 vaccine received Obtain 2nd vaccine
Negative or Equivocal No vaccine ever received Obtain both vaccines, have a titer drawn 30-days after the 2nd shot

Q—What should I do if the blood titers show I am not immune to the vaccine preventable disease(s)?
A—Unless you have a documented medical condition that contraindicates the administration of the vaccine(s), you may be required to be
vaccinated/revaccinated for those diseases that you have no immunity against.

Q—When is a rabies titer needed?

If you are a veterinary medicine student who has already completed the rabies vaccination series (3 vaccines) more than 2 years ago, you are
required to have a rabies titer and submit the titer results along with the dates you received each of the rabies vaccine. In accordance with
the Centers for Disease Control and Prevention (CDC), the recommended serum blood test for rabies is called rapid fluorescent focus
inhibition test (RFFIT). No other rabies testing results will be accepted. (CDC Rabies information:
http://cdc.gov/rabies/specific_groups/doctors/serology.html )

General Questions
Q—What would happen to me if I don’t complete the health clearance requirements?
A—Every incoming student, whether new to WesternU, repeating or returning from a leave of absence, is required to comply with all
health clearance requirements. If you do not complete these requirements, a registration hold will be placed, or in extreme cases, your
acceptance to attend WesternU may be rescinded.

Q—I am going to be returning to WesternU after being on a leave of absence for more than 6 months. Do I have to do the entire
health clearance process?
A—If you have already submitted serum titers (as described/required in the health clearance packet) and immunizations records, then
all you will need to submit is an updated medical history, physical exam, and TB clearance. Additionally, if your serum titers are more
than 4 years old, you will need to have them repeated.
Q—If my healthcare provider writes a note stating I have had a communicable disease, is this acceptable?
A—No. Documentation of select communicable diseases that were “physician diagnosed” and not confirmed through blood tests, are no
longer accepted as evidence of immunity. Because of this, the required vaccine preventable diseases that have blood tests to determine if
immunity exists or not (referred to as titers), are required for hepatitis B, measles, mumps, rubella, and varicella.

Q—If I have had the Hepatitis B disease and my physician states I do not need to have the Hepatitis B vaccination series, what should
I ask my physician to include in the health records and documents sent back to Western University?
A—Have your physician provide the lab test results that confirm a prior Hepatitis B diagnosis (see form D for the additional required serum
titers) and include a note about the status of your Hepatitis B disease [for example, “continue to monitor viral loads every 6 months”] on the
History and Physical examination form your physician completes. (This would also apply to those persons who have a “native immunity” to
Hepatitis B.)

Q—What if I have a health condition that is a contraindication to receiving a particular vaccination?

A—A letter from your healthcare provider attesting to this contraindication will be acceptable. However, if your current health status is
such that a particular immunization is temporarily contraindicated, you will still be responsible for obtaining that immunization as soon as
your health issue has resolved and prior to starting any clinical rotation.

Q—What if my religious beliefs do not allow me to be immunized?

A—There are no religious exemption from the University immunization requirements. One should explore with his/her healthcare provider
for the availability of vaccine formulations that do not involve the use of blood or select animal products, or document immunity as a result
of prior infection. The University’s commitment to minimize the potential harm to you and any patients or colleagues that you may
encounter in your future career is of paramount concern to the university. Only a legitimate medical contraindication to vaccination will
exempt a student from the University’s immunization requirements.

Q—Can I participate in clinical rotations if I am still updating/completing the required vaccines and TB clearance?
A—In order for you to be able to start your clinical rotations you must have had at least 2 doses of Hepatitis B vaccine, completed the
MMR and varicella series, have a current Tdap vaccine, as well as have a current TB clearance and the current influenza vaccination. You
must provide proof that you have completed all of the communicable disease clearance requirements or you will be removed from clinical
rotations; will not be allowed to register for the next semester; and if you receive financial aid, you will not receive your funds until
these requirements have been fulfilled.

Q—If I am pregnant can I be vaccinated safely?

A—Some vaccines can be administered safely during pregnancy. However, it is recommended that you consult with your obstetrician prior
to receiving any vaccines.

Q—If I am pregnant, can I participate in my clinical rotations without having completed the required vaccinations?
A—A pregnant student can receive a temporary medical exemption and still participate in some clinical rotations. However, it is strongly
recommended that you work closely with your faculty advisor to determine if it is permitted by the clinical site you would be going to as
well as your obstetrician.

Q—How long will it take to process my health clearance forms?

A—You will need to allow at least 10 (ten) business days from the date we receive all of your required health clearance forms. If you have not
received a confirmation email from the Student Health Office by the end of the 10th business day, you should contact us. Note: all forms are
processed on a first come, first served basis only.

Q—When is the deadline for submission of all my health clearance forms/documents? A—

Most colleges are June 1st. Review your offer letter for more detailed information.

Q—Once I have submitted all health clearance documents, will I have to do any other communicable disease tests, receive more
immunizations or obtain a physical exam?
A—You are required to obtain a yearly influenza vaccination and complete annual TB clearance and submit the documents to SHO.
Additional tests, vaccines and physical exams may be required for a clinical rotation site. It is your responsibility to confirm what is
needed to clear you to rotate any site. Please provide copies of any additional health clearance document to the Student Health Office.
Q—If I am feeling overwhelmed or my stress level is increasing, is there some place on campus where can I get help?
A—We have a department referred to as LEAD. They specialize in six main topics that support students through their academic journey
here at WesternU. These areas include a) one-on-one academic counseling, b) tutoring, c) the annual Summer Preparedness and Readiness
Course (SPaRC), d) the Wellbeing Initiative, e) LEAD CALM – Mindfulness Meditation Training & Practice, and f) various workshops
relevant to student life. All LEAD services are free of charge to the WesternU community, and all services are completely confidential.

If you need access to emergency student resources, please contact OPTUM the WesternU Student assistance
provider by phone at 800-234-5465 or by email www.liveandworkwell.com, use access code westernu.

Services available on the Pomona Campus

WesternU Health: Medical Center* WesternU Health Pharmacy
795 E. Second Street, Suite 5 795 E. Second Street, Suite 1
Pomona, CA 91766-2007 Pomona, CA 91766-2007
909-865-2565 909-706-3730

Services Provided Appointment is Required Open: Monday-Friday

Services Provided Hours: 8am to 5pm
NO appointment required
Physical Examinations Vaccinations Monday-Friday 8am to 430pm
Serum blood titers TB skin test

*Most health insurance plans are accepted. Physical exam fees are dependent upon medical needs as determined by
the health care provider. A discount is offered should you pay for the entire visit at the time of service.

Immunizations Cost per Vaccine from WesternU Health Pharmacy

Hepatitis B (Engerix B [3 shots]) $90.00
Hepatitis B (Heplisav B [2 shots]) $130.00
Influenza $35.00
MMR $98.00
PPD-TB skin test $25.00
Tdap $69.00
Varicella $182.00

Veterinary Students Only Rabies Vaccine $363.00 per vaccine if received at the WesternU Health Pharmacy

Cost if sent to
Serum Blood Titers
Lab Corp NOTE: If you chose to have your labs drawn at a
Hepatitis B Sur AB QN $75.25 facility other than the WesternU Health Medical
Rubeola AB IgG, EIA $26.75 Center, and you do not want to go to your
Rubella Antibodies, IgG $13.25 healthcare provider’s office, you must obtain
the lab order from the Student Health Office
Mumps Antibodies, IgG $23.00 BEFORE going to an outside lab for your blood
Varicella IgG AB $26.00 draw.
There will be a fee of $10.00 charged for the phlebotomy (blood draw process)
* Fees accurate as of 11-20-2019

Please note all prices listed may change without any notice.
For current pricing, contact the center at the numbers listed above.