AAMC Standardized Immunization Form

Middle
Last Name: BALOCH First Name: MARYAM FARHAN
Initial:
DOB: 01/21/2001 Street Address: NASHEMAN COLONY HOUSE NO 909
Medical School: ALLAMA IQBAL MEDICAL COLLEGE City: MULTAN
Cell Phone: +92 300 8347900 State: PUNJAB
Primary Email: [email protected] ZIP Code: 60000
Student ID: 15986935

MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose Copy
of Rubella; or serologic proof of immunity for Measles, Mumps and/or Rubella. Choose only one option. Attached
Option 1 Vaccine Date

MMR MMR Dose #1 04/23/2002

-2 doses of MMR ✔
vaccine MMR Dose #2 04/23/2006
Option 2 Vaccine or Test Date

Measles Vaccine Dose #1 Serology Results

Measles
-2 doses of vaccine or Measles Vaccine Dose #2 Qualitative
Titer Results:  Positive  Negative
positive serology ☐
Serologic Immunity (IgG antibody titer) Quantitative
Titer Results: IU/ml

Mumps Vaccine Dose #1 Serology Results

Mumps
-2 doses of vaccine or Mumps Vaccine Dose #2 Qualitative
Titer Results:  Positive  Negative
☐
positive serology
Serologic Immunity (IgG antibody titer) Quantitative
Titer Results: IU/ml

Serology Results
Rubella
-1 dose of vaccine or Rubella Vaccine Qualitative
Titer Results:  Positive  Negative

positive serology ☐
Serologic Immunity (IgG antibody titer) Quantitative
Titer Results: IU/ml

Tetanus-diphtheria-pertussis – One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide dates of last Td and Tdap

Tdap Vaccine (Adacel, Boostrix, etc) 07/21/2001

Td Vaccine (if more than 10 years since last
✔
☐
Tdap)
01/25/2012

Varicella (Chicken Pox) - 2 doses of vaccine or positive serology

Varicella Vaccine #1 04/19/2002 Serology Results

Varicella Vaccine #2 04/21/2006 Qualitative

Titer Results:  Positive  Negative ✔
☐

Serologic Immunity (IgG antibody titer) Quantitative

Titer Results: IU/ml

Influenza Vaccine - 1 dose annually each fall

Date
Date of last dose
☐
Flu Vaccine
COVID-19 Vaccine - 1 dose of updated (2023-2024 Formula) vaccine if Date
previously vaccinated with any COVID-19 Vaccine.

Updated Pfizer-BioNTech COVID-19 vaccine

Updated Moderna COVID-19 vaccine ☐

Novavax COVID-19 vaccine (2 doses given 3 weeks
apart if not previously vaccinated with any COVID-19
Vaccine)

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 AAMC Standardized Immunization Form
Name: BALOCH,MARYAMFARHAN Date of Birth: 01/21/2001
(Last, First, Middle Initial) (mm/dd/yyyy)

Hepatitis B Vaccination - 3 doses of Engerix-B, PreHevbrio, Recombivax HB or Twinrix vaccines or 2 doses of Heplisav-B vaccine followed by a
QUANTITATIVE Hepatitis B Surface Antibody test drawn 4-8 weeks after last vaccine dose. A test titer >10mIU/mL is positive for immunity. If the test result is Copy
negative, CDC guidance recommends that HCP receive one or more additional doses of Hepatitis B vaccine up to completion of a second series, followed by a
repeat titer test 4-8 weeks after the last vaccine dose. If a single additional vaccine dose does not elicit a positive test result, administer additional vaccine doses Attached
to complete the second series using the schedule approved for the primary series of a given product. If the Hepatitis B Surface Antibody test is negative (<10
mIU/mL) after receipt of 2 complete vaccine series, a “non-responder” status is assigned. See: http://dx.doi.org/10.15585/mmwr.rr6701a1 for additional
information.
3-dose vaccines (Energix-B, PreHevbrio,
Recombivax HB, Twinrix) or 3 Dose Series 2 Dose Series
2-dose vaccine (Heplisav-B)

Primary Hepatitis B Vaccine Dose #1 02/23/2001

Hepatitis B Series

Heplisav-B only requires two

Hepatitis B Vaccine Dose #2 03/23/2001 ✔
☐
doses of vaccine followed by
antibody testing Hepatitis B Vaccine Dose #3 04/21/2001
QUANTITATIVE Hep B Surface
Antibody Test mIU/ml

Additional doses of 3 Dose Series 2 Dose Series

Hepatitis B Vaccine
Hepatitis B Vaccine Dose #4
Only If no response to
Hepatitis B Vaccine Dose #5
primary series
Heplisav-B only requires two Hepatitis B Vaccine Dose #6
doses of vaccine followed by
antibody testing QUANTITATIVE Hep B Surface
Antibody Test mIU/ml

If the Hepatitis B Surface Antibody test is negative (titer less than 10 mIU/mL) after a
primary and repeat vaccine series, vaccine non-responders should be counseled and
Hepatitis B Vaccine
evaluated appropriately. Certain institutions may request signing an “acknowledgement
Non-responder
of non-responder status” document before clinical placements.

Additional Documentation

Some institutions may have additional requirements depending upon rotation, school requirements or state law. Examples
include meningitis vaccine which is mandated in some states if you live in dormitory style housing. If you will be participating in
an international experience, you may also be required to provide proof of vaccines such as yellow fever or typhoid.

Vaccination, Test or Examination Date Result or Interpretation

Physical Exam (if required)

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 AAMC Standardized Immunization Form
Name: BALOCH, MARYAM FARHAN Date of Birth: 01/21/2001
(Last, First, Middle Initial) (mm/dd/yyyy)

TUBERCULOSIS (TB) SCREENING – All U.S. healthcare personnel are screened pre-placement for TB. Two kinds of tests are used to
determine if a person has been infected with TB bacteria: the TB skin test (TST) and the TB blood test (IGRA). Results of the last two TSTs or
one IGRA blood test are required regardless of prior BCG status. If the TST method is used, record the dates and results of two 1-step annual
TSTs over the last two years, or of one 2-step TST protocol (two TSTs performed with the second TST placed at least 1 week after the first TST
read date). In either series, the second TST must have been placed within the past 12 months prior to clinical duties, and must have been
performed in the U.S. If you have a history of a positive TST (PPD) >10mm or a positive IGR blood test, please supply information regarding any
evaluation and/or treatment below. You only need to complete ONE section, A or B.

Skin test or IGRA results should not expire during proposed elective rotation dates or
must be updated with the receiving institution prior to rotation.

Tuberculosis Screening History

Section A Date Placed Date Read Result Interpretation

TST #1 12/06/2022 12/08/2022 0 mm  Pos  Neg  Equiv

TST #2 04/08/2023 04/10/2023 0 mm  Pos  Neg  Equiv

Please complete only one TB section based on your history

History of
Negative TB Skin
Test or Blood
Test
Date Result

T-spots or QuantiFERON QuantiFERON TB Gold or T-Spot  Positive  Negative  Indeterminate

TB Gold blood tests for (Interferon Gamma Releasing Assay)
tuberculosis
QuantiFERON TB Gold or T-Spot  Positive  Negative  Indeterminate
Use additional (Interferon Gamma Releasing Assay)
rows as needed

Section B Date Placed Date Read Result

Positive TST mm
Date Result

QuantiFERON TB Gold or T-Spot  Positive  Negative  Indeterminate

(Interferon Gamma Releasing Assay)
History of
Positive Skin
Chest X-ray* *Provide documentation or result
Test or
Positive Blood
Test Treated for latent TB infection (LTBI)?  Yes  No

Date of Last Annual TB Symptom Questionnaire

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 AAMC Standardized Immunization Form
Name: BALOCH, MARYAM FARHAN Date of Birth: 01/21/2001
(Last, First, Middle Initial) (mm/dd/yyyy)

Additional Information
This is to certify that Ms. Maryam Farhan Baloch has undergone a detailed medical evaluation,
including physical examination and relevant diagnostic tests, and has been found to be in excellent
health. She exhibits no signs of any underlying disease, disorder, or medical condition.

Her cardiovascular, respiratory, neurological, and musculoskeletal systems are functioning

normally, with all vital signs within the healthy range. She is free from any chronic illnesses,
infections, or physical impairments. Additionally, there are no indications of psychological or
emotional health concerns at this time.

Based on the results of this comprehensive evaluation, Ms. Maryam Farhan Baloch is deemed
physically fit and capable of performing all routine and strenuous activities without restriction.

MUST BE SIGNED BY A LICENSED HEALTHCARE PROFESSIONAL OR DESIGNEE:

Healthcare Professional
Signature: Date:

Printed Name:
Office Use Only
Title:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Phone: ( ) - Ext:

Fax: ( ) -

Email Contact:

*Sources:
1. Hepatitis B In: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds.
13th ed. Washington D.C. Public Health Foundation, 2015
2. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, Vol 60(7):1-45
3. CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, MMWR, Vol 62(RR10):1-19
4. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, MMWR Vol 67(1):1-31
5. Sosa LE, Nijie GL, Lobato MN, et.al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from National Tuberculosis
Controllers Association and CDC, 2019. MMWR2019;68:439-443. https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s cid+mm6819a3 w

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