Forms

Welcome to Lipscomb! In order to serve you, all students must have a Health Record Form on file in the Student Health Center.
 
There is one form for UNDERGRADUATE STUDENTS* and one for GRADUATE STUDENTS.
*Pharmacy, nursing, and dietetic students must fill out the UNDERGRADUATE HEALTH FORM for correct immunization documentation.
 
The form must be completed on both sides. It is required prior to class registration and incomplete forms could cause a hold to go on your record until all pieces are complete.
 
The Health Record Form (both sides) must also be completed and submitted with the following documentation to comply with the state of Tennessee's requirements.
  1. MMR (Measles, Mumps, Rubella) vaccination.  Required for all students born after 1956. You must submit copies of documentation of two MMR immunizations given 4 weeks apart or 2 doses of each vaccine: measles, mumps, and rubella. If you think you have had the immunizations but do not have proof, then you need to have a blood test (a titer*) to see if you are immune for all three diseases. A copy of your titers is acceptable, but if you do not have acceptable levels of antibodies then you must get a MMR booster.  
  2. TB screening. Required for all students. We have a TB Risk Assessment Tool if you are unsure of whether you need a TB screening test. If any “yes” answers, one of our nurses will need to determine whether you require a TB test. All pharmacy, nursing, and dietetic students must have a TB test within the past 12 months. Talk to your program coordinator for details. A TB test can be any of the following: a PPD skin test, a Quantiferon Gold blood test, or chest x-ray administered within the past 12 months. If you are a returning student and have not been enrolled in school for one calendar year or more, you are required to repeat this test upon your admission. 
  3. Hepatitis B vaccination. A series of three (3) doses of the vaccine are required for all students. Those students who are not in a health science program (pharmacy, nursing, and dietetic interns) may sign a waiver of declination. Missed doses may still be sought after matriculation if only one or two have been acquired. Pharmacy, nursing, and dietetic intern students must have the Hepatitis B series or a positive titer* (Hepatitis B Surface Antibody).
  4.  Meningitis vaccination. Required for all new residential students. If a student decides to decline receipt of the meningitis vaccination, then a waiver of declination must be signed.
  5. Varicella. All new students born after 1979 must show proof of varicella (chickenpox) immunity through one of three ways: 1. Proof of 2 varicella vaccines given 4 weeks apart. 2. A positive titer* to varicella zoster. 3. Documentation of varicella infection from a healthcare provider.

 

Pharmacy and Nursing Students must receive 

Varicella vaccinations (series of two) or must submit proof of immunity by means of a titer. History of disease is not acceptable--a titer* must be drawn. 

Tetanus/diptheria vaccinations - booster must be within the past 10 years (Td or Tdap).   

Tips on finding immunization records:

 Please note: LU Student Health Services does NOT require a physical examination prior to admission though it is a good idea.

IMPORTANT: Failure to provide any of the items means your file is not complete and may prevent class registration!
 
The Health Center is located on the lower level of Elam Hall adjacent to the Counseling Center. 

If you have questions, please contact the Health Center at (615) 966-6304 or 1-800-333-4358 ext. 6304 or email Melanie at melanie.stewart@lipscomb.edu. Our fax number is (615)966-5286.
You may also mail your Health Record Form to:
 
Lipscomb University Health Center
One University Dr. 
Nashville, TN 37204
 

 

 

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