EFTA00521852.pdf

Immunization History Columbia University Medical Center Student Health Service Columbia University Medical Center Student Health Service 630 W. 168th Street Box 77 New York, NY 10032 (212) 305-3400 Patient Information Name: Shuliak. Karyna Address: DOB: ID: Vaccination History Name Date On Site Additional Information BCG 06/05/1989 N DT 05/11/2000 N DTP 10/25/1995 N DTP 06/11/1991 N DTP 11/30(1989 N Hepatitis B 03/04/2003 N Hepatitis B 04/18/2003 N Hepatitis B 10/21/2003 N Influenza split virus vaccine, IM 10/22/2013 Exposure; 0.5mI; IM; Deltoid Influenza split virus vaccine, IM 09/19/2012 Exposure; 0.5mI; IM; Deltoid Initial Health Assessment 05/24/2012 N Measles 06/08/1990 N Measles 07/31/1995 N Mumps 03/26/1991 N OPV (Polio) 10/25/1995 N OPV (Polio) 06/11/1991 N OPV (Polio) 08/13/1991 N PPD Planted 11/11/2013 Other; 0.1 ml: Intradermal; Arm PPD Planted 05/29/2012 Other; 0.1ml; Intradermal; Arm Rubella 02/14/2005 N Tetanus, diphtheria toxoids and 05/24/2012 Exposure; 0.5mI; injection; Arm acellular pertussis vaccine (Tdap) for IM use Titer Results Name Date Result Note Hepatitis B 05/25/2012 Positive 1.90 Hepatitis C 05/25/2012 Negative <0.1 Measles 05/25/2012 Positive 2.08 Mumps 05/25/2012 Positive 1.72 Rubella 05/25/2012 Positive 372 Varicella 05/25/2012 Positive 2.85 Incidences of Disease None Tuberculosis History Report Date: 02/13/2014 Page 1 of 2 EFTA00521852 Immunization History Columbia University Medical Center Student Health Service Columbia University Medical Center Student Health Service 630 W. 168th Street Box 77 New York, NY 10032 (212) 305-3400 Patient Information Name: Shuliak. Karyna Address: DOB: ID: Name Date Result Date Result Note PPD 11/11/2013 11/13/2013 Negative (0 mm) PPD 05/29/2012 05/31/2012 Negative (0 mm) PPD 09/20/2003 09/20/2003 Negative (7 mm) Exemptions Name Expiration Date Reason Meningococcal 05/31/2022 Waived Report Date: 02/13/2014 Page 2 of 2 EFTA00521853