Dear Thorobred:

Student Health Services recommends all students submit the Medical History Form, Preventative Health Care Examination Form, and an Immunization Record prior to attending Kentucky State University.

Documentation from a doctor or clinic regarding the following immunizations is recommended:

• Preventative health care examination completed by doctor or clinic within the past six months
• Tuberculin Skin Test within the past six months
• Copy of chest X-ray if history of positive tuberculin test

Recommended immunizations include:

• Polio Series (x 4)
• Adult Tdap (within the past 10 years)
• Meningitis Vaccine (up to age 26)
• Mumps (MMR x 2 or documentation of disease)
• Varicella Vaccine/Chicken pox (x 2 or documentation of disease)

Note: Documentation of disease should be verified or signed on a physician's or clinic's letterhead.

Please send the following completed forms and immunization record to:

Office of Admissions Kentucky State University ASB Suite 312 400 E. Main St. Frankfort, KY 40601

Or fax to: (502) 597-5814

Thanks for your cooperation!

Sincerely,

Floarine A. Wilson, APRN Director, Betty White Health Center

Rev 2/22/16