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IMMUNIZATION RECORD NAME LAST D. O. B SNAPS FIRST COUNTRY OF ORIGIN UID EMAIL SHAC CARE ADVOCATE INTERN - DEPT VOLUNTEER - DEPT Copies of immunizations and labs must be attached to this form DATE TITER DATE MMR Measles Mumps Rubella Varicella Hepatitis B Tdap Influenza DATE GIVEN DATE READ RESULTS PPD 1 PPD 2 Quantiferon FOR HEALTH CENTER USE ONLY Initials Cleared Not Cleared MAIL University Health Center Building 140 Campus Drive College Park MD 20742 FAX 301 314-5234 PHONE 301 314-8139.
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