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Rowan University *

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CS-00100

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Medicine

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Oct 30, 2023

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Immunization Form Due Dates: Incoming Fall & Summer Students - June 15, Incoming Spring Students - December 15t ¢ A 7[0S~ Last Name First Name M.L Date of Birth: M/D/Y Banner ID# MEASLES, MUMPS, RUBELLA (MMR): = 2 doses of vaccine administered, on or after 12 months of age, and at least 28 days apart are required, OR = Laboratory proof of immunity; copy of Measles (Rubeola), Mumps, and Rubella Virus IgG Antibody laboratory titer report MUST be attached if submitting in lieu of immunization dates. EQUIVICAL RESULTS NOT ACCEPTABLE. MEASLES: 1:_ /[ __ MMRDose1: /[ Must attach S o MEASLES, MUMPS REQUIRED FOR MUMPS: 1./ [/ : AND RUBELLA IgG /—/ « ALL STUDENTS Titer Lab Report e Born AFTER 1956 Showing positive immunity. RUBELLA: 1:__/_ [/ 2/ / MMRDose2:___/_ / HEPATITIS B - a copy of a Hepatitis B IgG Surface Antibody (anti-HBc) laboratory titer report MUST be attached if submitting in lieu of immunization dates. EQUIVICAL RESULTS NOT ACCEPTABLE. HEPATITIS B vaccine HEPATITIS A and B combined REQUIRED FOR ALL: n mbl Must attach = FULL-TIME Dosel: /_/— L HEPATITS B IgG Titer Lab | STUDENTS - taking 12 or more credit Dose2:__/__ [ PR iy N Report showing positive immunity. hours; and/or Dose3:__/__/___ 32/ 3 = NCAA ATHLETES MENINGOCOCCAL MENINGITIS - VACCINE MUST BE ADMINISTERED ON OR AFTER 16t BIRTHDAY. BOOSTER DOSE may be required if administered more than 5 years prior to the start of classes. **x+you will not be permitted to move into campus housing without this information*** MENINGOCOCCAL B MENINGOCOCCAL A, C, Y,W- REQUIRED FOR ALL: 135 (Menactra or Menveo) |= 18 & YOUNGER Bexsero Trumemba m‘:&g&gfi ‘?SSY Do s = RESIDING IN CAMPUS HOUSING | ;. : = NCAA ATHLETES %/ /— |%—/—/— | MENINGITIS Dose2: [/ « AS INDICATED BY MENINGITIS |2/ /__ |2:__/_/__ | QUESTIONNAIRE QUESTIONNAIRE FORM e E el iEORM Highly Recommended COVID-19 Manufacturer: Manufacturer: Manufacturer: Dose 1: /. / Dose 2: Ry il Booster: ____/. / For more information on NCAA health requi TETANUS - Booster in the last 10 years. | Sickle Cell Trait REQUIRED FOR ALL: Tdap ™D Confirmation of Sickle Cell Trait status with either = NCAA ATHLETES Dose:__/_ /| Dose:__j__/_ documentation from birth or recent SCT screening. Physician/PA/NP Address: Toot Coitw &= Morristown, NJ 07960 Physician/PA/NP Signature: Rowan University « Wellness Center « Winans Hall « 201 Mullica Hill Road « Glassboro, NJ 08028 856.256.4333 (phone) « wellnesscenter@rowan.edu (email) e www.rowan.edu/wellness

ARy LAIVITUVIRIN INE LY 120 /UVUTY) Page 10of3 Immunization Summary Eamon Kinney MRN: HNE1912870099 Patient Information ¥ Bt g PO A Patient Name Legal Sex DOB Kinney, Eamon Male 9/7/2005 Immunizations by Immunization Family DTaP 11/7/2005 (2 1/9/2006 (4 3/6/2006 (5 9/13/2007 (2 y.0.) m.o.) m.o.) m.o.) 8/18/2010 (4 8/24/2016 (10 y.0.) y.0.) HPV, Unspecified 8/17/2022 (16 9/19/2022 (17 i ~yo) y-0.) - Hep A, Unspecified 9/16/2011 (6 10/29/2012 (7 y.0.) y.0.) Hep B, Unspecified 11/7/2005 (2 1/9/2006 (4 12/12/2006 (15 m.o.) m.o.) m.o.) HiB 11/7/2005 (2 1/9/2006 (4 12/12/2006 (15 m.o.) m.o.) m.o.) Influenza, Unspecified 1/16/2009 (3 9/1/2020 (14 y.0.) y.0) MMR 12/12/2006 (15 8/18/2010 (4 m.o.) y.0.) Meningococcal Conjugate 8/24/2016 (10 8/17/2022 (16 (MenACWY) y.0.) y.0.) PPD Test 8/18/2010 (4 8/24/2015 (9 y.0.) y.0.) Pneumococcal Conjugate, 11/7/2005 (2 1/9/2006 (4 3/6/2006 (5 12/12/2006 (15 Unspecified m.o.) m.o.) m.o.) m.o.) Polio, Unspecified 11/7/2005 (2 1/9/2006 (4 9/13/2007 (2 8/18/2010 (4 y.0.) m.o.) m.o.) y.0.) Varicella (Chicken Pox) 12/12/2006 (15 8/17/2009 (3 m.o.) y.0.) No results found for: PPD Immunizations/Injections Name Date Dose VIS Date Route Exp Date DTaP 11/7/2005 - - = = DTaP 1/9/2006 - -- -- =3 DTaP 3/6/2006 -- -- -- i3 DTaP 9/13/2007 - -- -- -- DTaP 8/18/2010 -- -- -- -- DTaP 8/24/2016 -- -- -- £ HPV 9-Valent 8/17/2022 0.5 mL 8/6/2021 Intramuscular 3/11/2023 4:12 PM Kinney, Eamon (MRN HNE1912870099) Printed by Sean Kneese [SKNEESO01] at 5/17/2023 2:10 PM

Kinney, Eamon (MRN HNE1912870099) Page 2 of 3 Name - Date Dose VIS Date Route Exp Date Manufacturer: Merck & Co. Inc ik ) Lot: T038529 ComjipenteCle, - - & e Ut i R * HPV 9-Valent 9/19/2022 0.5mL 8/6/2021 Intramuscular 4/30/2023 4:57 PM Manufacturer: Merck & Co. Inc Lot: 1687293 Comment: YL B B - . Hep A, 2 Dose Pediatrics, 1-18 9/16/2011 - -- e i years Bt 3 Hep A, 2 Dose Pediatrics, 1-18 10/29/2012 -- = = o years i e Hep B, Adolescent Or 11/7/2005 -- 22 2 - Pediatric, 0-19 years = i ae e S Hep B, Adolescent Or 1/9/2006 -- - - - Pediatric, 0-19 years Hep B, Adolescent Or 12/12/2006 -- - -- = Pediatric, 0-19 years HiB i 11/7/2005 -- -- -- - HiB 1/9/2006 -- -- -- - HiB 12/12/2006 -- = S = Influenza 2019-20 (4 Years 9/1/2020 0.5mL - - - Up) (PF) Quadrivalent IM (Cell Derived) Lot: 279827 Influenza, Unspecified 1/16/2009 -- -- -- =2 MMR 12/12/2006 -- - -- - MMR 8/18/2010 - - -- -- Meningococcal Conjugate 8/24/2016 = = - -- (MenACWY, MCV4) (Menactra, Menveo) 5 Meningococcal Conjugate 8/17/2022 0.5mL 8/6/2021 Intramuscular 1/18/2023 (MenACWY, MCV4) (Menactra, Menveo) Manufacturer: Sanofi Pasteur Lot: U7191AB Comment:CL 3 : 5 i PPD Test 8/18/2010 = == o 2% PPD Test 8/24/2015 -- -- -- -- Pneumococcal Conjugate 13- 11/7/2005 - - -- -- Valent Pneumococcal Conjugate 13- 1/9/2006 - -- L2 = Valent Pneumococcal Conjugate 13- 3/6/2006 2 == B - Pneumococcal Conjugate 13- 12/12/2006 -- - = s Valent Kinney, Eamon (MRN HNE1912870099) Printed by Sean Kneese [SKNEESO01] at 5/17/2023 2:10 PM

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Kinney, Eamon (MRN HNE1912870099) Name Date Dose VIS Date Route Exp Date Poliovirus 11/7/2005 -- — = X Poliovirus 1/9/2006 - o i = Poliovirus 9/13/2007 - i = = 3 Poliovirus 8/18/2010 - = g i Varicella (Chicken Pox) ~ 12/12/2006 -- - -- = A Varicella (Chicken Pox) 8/17/2009 - = = s Kinney, Eamon (MRN HNE1912870099) Printed by Sean Kneese [SKNEES011.at /177072 7-10 bt