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Name Student ID# Date of Birth Program/Graduation Yr THIS FORM IS TO BE COMPLETED BY YOUR LICENSED HEALTHCARE PROVIDER ONLY IF YOU HAVE A NEGATIVE OR INDETERMINATE HEPATITIS B TITER. COPIES OF MEDICAL RECORDS/LABS WILL NOT BE ACCEPTED. Hepatitis B Booster AND 2nd Titer Required Booster Date: _______ Initials: ________ Titer #2 (1 - 2 months after booster) Date: _______ Initials: _________ (Dose #4) Circle result: Positive Negative Indeterminate **IMPORTANT: If your booster titer result above is negative or indeterminate, you are required to repeat the full series of Hepatitis B doses and titer. Heplisav-B vaccine series is accepted. See below: Hepatitis B (Complete this only if titer above is negative or indeterminate) Hepatitis B (Complete this only if titer above is negative or indeterminate) OR Heplisav Engerix Twinrix (Hep A & B) Dose #5 date: _________ Initials: __________ Dose #5 date: _______ Initials: __________ 3RD TITER (Required after either series above) Date: __________ Circle result: positive negative indeterminate Health Care Provider Initials: _________ Licensed Health Care Provider Attestation By signing below, I affirm that I am a licensed health care provider. I am aware that leaving any required fields blank will result in the student being unable to progress in his/her major at the University of Vermont. Signature of Licensed Health Care Provider Credentials Date Clinic Stamp or Printed Name of Provider Provider Telephone Number The information included on this form maybe released to the infection control officer and clinical education coordinators at sites where you perform your clinical education experience. COLLEGE OF NURSING & HEALTH SCIENCES Dose #6 date: _________ Initials: __________ Timeline for doses: Get 4th dose, get 5th dose 1 month later, get 6th dose 4 months from 4th dose; Get titer 1 to 2 months after 6th dose. Healthcare provider: If Engerix or Twinrix is used, please note on Dose 4 (booster), 5 and 6. HEPATITIS B BOOSTER AND HEPATITIS B SECOND SERIES FORM Timeline for doses: Get 4th dose, get 5th dose 1 month later, get titer 1 to 2 months after 5th dose. Healthcare provider: If Heplisav-B is used, please note on Dose 4 (booster) and 5.

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Page 1: THIS FORM IS TO BE COMPLETED BY YOUR LICENSED …

Name

Student ID#

Date of Birth

Program/Graduation Yr

THIS FORM IS TO BE COMPLETED BY YOUR LICENSED HEALTHCARE PROVIDER ONLY IF YOU HAVE A NEGATIVE OR

INDETERMINATE HEPATITIS B TITER. COPIES OF MEDICAL RECORDS/LABS WILL NOT BE ACCEPTED.

Hepatitis B Booster AND 2nd Titer Required

Booster Date: _________ Initials: ________ ___Titer #2 (1 - 2 months after booster) Date: _______ Initials: _________

(Dose #4)

Circle result: Positive Negative Indeterminate

**IMPORTANT: If your booster titer result above is negative or indeterminate, you are required to

repeat the full series of Hepatitis B doses and titer. Heplisav-B vaccine series is accepted. See below:

Hepatitis B (Complete this only if titer above is negative or indeterminate) Hepatitis B (Complete this only if titer above is negative or indeterminate)

OR HeplisavEngerix

Twinrix (Hep A & B)

Dose #5 date: _________ Initials: __________

Dose #5 date: _______ Initials: __________

ate:

3RD TITER (Required after either series above)

Date: __________

Circle result: positive negative indeterminate

Health Care Provider Initials: _________

Licensed Health Care Provider Attestation

By signing below, I affirm that I am a licensed health care provider. I am aware that leaving any required fields blank

will result in the student being unable to progress in his/her major at the University of Vermont.

Signature of Licensed Health Care Provider Credentials Date

Clinic Stamp or Printed Name of Provider Provider Telephone Number

The information included on this form maybe released to the infection control officer and clinical education coordinators

at sites where you perform your clinical education experience.

COLLEGE OF NURSING & HEALTH SCIENCES

Dose #6 date: _________ Initials: __________Timeline for doses: Get 4th dose, get 5th dose 1 month later,

get 6th dose 4 months from 4th dose; Get titer 1 to 2 months after 6th dose.

Healthcare provider: If Engerix or Twinrix is used, please note on Dose 4 (booster), 5 and 6.

HEPATITIS B BOOSTER AND HEPATITIS B SECOND SERIES FORM

Timeline for doses: Get 4th dose, get 5th dose 1 month later,

get titer 1 to 2 months after 5th dose.

Healthcare provider: If Heplisav-B is used, please note on Dose 4 (booster) and 5.

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