Name (please print):

Please complete and return this form to the Volunteer Program.

Section 1: ALL Volunteers - Immunization Requirements To protect our patients, guests, staff and volunteers, CentraCare has a policy requiring a mandatory influenza vaccination. Unvaccinated employees and volunteers are required to wear a mask until the end of the flu season. Upon becoming an active volunteer you will be eligible to receive a free flu shot. Please contact the Volunteer Program if you have questions.

Section 1: Influenza (Flu) Vaccine please check the box next to the letter that applies:

A. I submitted records of an influenza vaccination. B. I plan to receive the influenza vaccination free of charge upon becoming an active volunteer C. I do not have records of the influenza vaccination and I plan to wear a mask while volunteering.

Section 2,3,4: Patient Service Volunteers - Immunization Requirements Employee Health Services (EHS) follows the recommended guidelines from the Center for Disease Control (CDC). These

immunization record requirements are necessary to protect you, our patients, guests, employees and volunteers.

Section 2: Chicken Pox (Varicella) please check the box next to the letter that applies:

A. I submitted a medical records of Two Varicella vaccines at least 28 days apart. B. I submitted a medical statement or dictation note from a healthcare provider indicating I was

seen and diagnosed with Varicella (chicken pox) or Zoster (shingles). C. I submitted medical records indicating I received the Zoster (shingles) vaccination. D. I am not able to provide the information in A, B or C. Please see Section 4.

Section 2: Measles, Mumps and Rubella (MMR) please check the box next to the letter that applies:

A. I submitted records of two vaccines for MMR at least 28 days apart. B. I do not have records of vaccines for MMR. Please see Section 4.

Section 3: Tuberculosis (TB) Skin Test please check the box next to the letter that applies:

A. I will need a TB Skin Test provided free of charge at my EHS volunteer screening appointment. B. I submitted a copy of negative TB skin test result within the past 12 months. C. I will provide a copy of a positive skin test results and a chest X-ray within the past 2 years. NOTE: The TB skin test should be given and read prior to you receiving an MMR or Varicella shot.

Section 4: I cannot provide records to fulfill these Immunizations Record Requirements We understand it may be challenging to locate immunization records, medical statements, or dictation notes. Please check for immunization records at the entities applicable to you in the table below to help us understand your situation.

Entity Contacted Entity Contacted

Doctor’s Office or Clinics Department of Human Services

School (high school or college) U.S. Citizenship and Immigration Services

Military Records Current / Former Employer

Minnesota Department of Health Other:

What if I don’t know if I had the diseases or I don’t have any proof of having the diseases? You can have your blood titer drawn to see if your body shows immunity. EHS will provide you with a slip to take to the lab to have your blood drawn free of charge. If you do not show immunity, you will need to obtain the recommended vaccines at your own cost before you are cleared to start orientation.

Check with your health care provider to see what is best for you.

Send completed form to volunteer@centracare.com or fax to 255-5817.

Minnesota Department of Health

Tips for Finding Immunization Records Immunization records are important for you and your family. Shot records are needed for doctor’s visits

and to meet child care and school immunization requirements and may be needed for a job or for

international travel. Here are some tips on locating immunization records.

Where can I look for old records?

● Family records. Family records such as

baby books may contain immunization

records.

● Doctor’s offices or clinics. Check with all health care providers where shots may

have been given, including neighborhood

clinics and local public health departments.

● Schools or child care providers. Child care providers and schools must verify

immunizations for attendees and may be

able to look up records.

● Military records may be a source of

immunization information for those who

have served in the military.

● An immunization registry. Registries are confidential, computerized systems

for tracking immunization records. They

are managed by state or local health

departments and are accessible only by health professionals who give

immunizations or those required by law

to record immunizations for enrollment.

Locating the vaccination history of an adult is

oftentimes difficult. Clinics, schools, and child

care providers maintain records for a limited

period of time and very few immunization

registries existed prior to the mid-1990’s. In the

future, immunization registries will provide

complete records of shots received, regardless of

where or at what age they were given.

What immunization records are in the

Minnesota immunization registry, MIIC?

The Minnesota Immunization Information

Connection, or MIIC, includes a record of shots given at numerous public and private health care

clinics and hospitals in Minnesota. The registry

covers all ages but is more likely to contain

immunization records of children than adults.

Also, although MIIC participation by clinics and

hospitals continues to expand, not all health care

providers participate. Check to see if your clinic

participates in MIIC at

www.health.state.mn.us/divs/idepc/immunize/reg

istry/counties.html.

How can I check MIIC for

immunization records?

To find out if immunization records for you or

your family are in MIIC, contact the Minnesota

Department of Health MIIC Help Desk at 651-

201-5503 or 800-657-3970. You will be asked to verify your identification and if your records are

in the registry, they can be sent to you via fax or

mail. Due to confidentiality concerns,

immunization records cannot be sent via email.

Note: if you are a health care provider please

contact your MIIC regional coordinator for

assistance with immunization records in MIIC.

Their contact information is available at

www.health.state.mn.us/divs/idepc/immunize/reg

istry/map.html.

What about shots received in other

states?

Most states and some local areas have

immunization registries. Try contacting the

registry in the location where you or your child

received their last shots. See a list of state and

local registries at

www.cdc.gov/vaccines/programs/iis/contacts-

state-iis.htm.

What if I can’t find my records?

If immunization records can’t be found, it may be

necessary to repeat some of the shots or arrange

for blood tests to determine immunity. Talk with

your doctor to determine the appropriate course

of action. Keep track of immunizations received

by using the forms at

www.health.state.mn.us/divs/idepc/immunize/tra

cking.html.

Immunization Program

P.O. Box 64975

St. Paul, MN 55164-0975

651-201-5503, 800-657-3970

www.health.state.mn.us/immunize

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