Graduate Medical Education

701 W. 5th Street

Odessa, TX 79763

Telephone (432) 703-5124

Fax (432) 335-5332

Pre-Matriculation Health Requirements

Copies of immunization records, laboratory reports, and radiology reports must be included with this form. You
must have IgG antibody titers drawn to document immunity.

Required Immunizations:

_____DPT Diphtheria, pertussis, tetanus. Childhood series of 5 vaccinations. If your immunization

record is not available, please contact your high school or college for documentation.

_____Tdap Tetanus, Diphtheria, a cellular pertussis. Booster given to adult health care workers

____Rubeola Measles. Childhood series of 2 vaccinations AND positive IgG antibody titer.

____Mumps Childhood series of 2 vaccinations AND positive IgG antibody titer.

____Rubella German measles. Childhood vaccination AND positive IgG antibody titer.

____Varicella Chicken pox. Two doses of vaccine AND positive IgG antibody titer. History of
varicella diseases is not acceptable.

_____ Hepatitis B Three doses of vaccine and a positive quantitative hepatitis B surface antibody titer. If
you have never been vaccinated, you can schedule an appointment to receive the first
dose during orientation week.

PPD:
Date Placed: _____/______/______ Date Read: ____/____/____ Results _____mm

Health –Care Provider Name: _______________________ Phone Number: ______________

NOTE:
 If you have had a positive PPD & or received BCG please provide documentation on negative chest x-ray.
 TTUHSC Administers Tuberculosis (TB) screening to all Residents and Fellows prior to beginning the residency
program and annually thereafter.

701 W. 5th Street

T 432.703.5124~ F 432.335.5332
Bethany.wright@ttuhsc.edu

An EEO/Affirmative Action Institution