Healthcare Personnel Testing and Immunization Requirements


  1. The University of New Mexico Health Sciences Center recognizes its responsibility to provide a workplace free of recognized hazards.
  2. Disease screening practices, immunity assessment, and vaccination protects patients and staff and the integrity of the University of New Mexico Health System (Health System).
  3. This policy is intended to minimize risk for possible transmission of vaccine-preventable diseases among the personnel of the Health Sciences Center whose work requires their presence in patient care settings. The goal is to protect patients, employees, employees' family members, others affiliated with the Health System, and the broader community.
  4. Recognizing we are an academic institution that supports the training and education of the community, we must require compliance from all individuals who enter our facilities for business or academic purposes.


  1. This policy applies to all Health Care Personnel (HCP). HCP is defined as all who provide services or work in patient care or clinical care areas. HCP for purposes of this policy include the following:
    1. Employees of the following entities:
      1. Sandoval Regional Medical Center (SRMC)
      2. UNM Comprehensive Cancer Center
      3. UNM Hospitals
      4. UNM Medical Group
      5. Other UNM Health Sciences Center employees and students within the UNM School of Medicine, College of Nursing, College of Pharmacy and all other allied health programs.
    2. Any newly created Health Sciences Center entities providing a patient care setting.
  2. Any non-employee who provides services or work in patient care or clinical care areas such as volunteers; vendors; external allied health students, residents, or personnel; and external health care providers.
  3. Each Health Sciences Center entity and their organized medical staff as listed in l.a above shall enforce these minimum standards through written policies.
  4. Individual HCP have the responsible to be compliant with meeting these standards.
  5. This policy shall be managed by the UNM Health Sciences Center Immunization Committee. The policy is to be updated and modified based on changes in local, state and federal requirements, laws, and current best practices.
    1. Each Health Sciences Center entity shall modify their policies to remain compliant with changes to these standards.


  • HIPAA Privacy- 45 CFR Parts 160 and 164. ("Notice to Employees" relating to workplace protected health information)
  • OSHA Bloodbome Pathogens Standard 29 CFR 19.1030
  • Needlestick Safety and Prevention Act (Pub. L. 106-430)
  • New Mexico Requirements for Acute Care, Limited Services, and Special Hospitals, 7.7.2
  • NMAC Section 21, effective 6/15/04
  • Centers for Disease Control and Prevention (CDC) Health Care Personnel Recommendations
    1. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP) published in the Morbidity and Mortality Weekly Reports MMWR. 2011; 60(RR07):1-45.
    2. Maintained and updated recommendations online 


  1. The Health Sciences Center requires HCP to be in compliance with the following requirements for screening, immunity assessments and immunizations (See Appendix 1 for specific immunization requirements).
  2. Baseline Compliance Requirements:
    1. Measles, Mumps and Rubella Proof of Immunity
    2. Varicella Proof of Immunity
    3. Tuberculosis (TB) Baseline Screening
    4. Hepatitis B (if applicable) OSHA Compliance
  3. Annual Compliance Requirements:
    1. Influenza Vaccination
    2. Tuberculosis (TB) Screening (if applicable)
  4. Highly Recommended HCP Immunization:
    1. Tetanus, Diptheria and Acellular Pertussis (Tdap)
  5. All screenings, assessments, diagnostics and vaccinations shall be provided to employees through the following clinics:
    1. Occupational Health Services (UNMH OHS)
      1. UNMH Employees
    2. Employee Occupational Health Services (UNM EOHS):
      1. UNM
      2. UNM Medical Group
      3. UNM Cancer Center
    3. Sandoval Regional Medical Center Occupational Health (SRMC OHS)
      1. SRMC Employees
    4. Employee baseline compliance requirements will be initiated before or at a new hire Pre­Placement Health Screen through procedures under the direction of each of the listed clinics.
    5. Annual compliance requirements will be completed through procedures under the direction of each of the listed clinic.
  6. All other HCPs not identified in 5 above must have documented proof of meeting the
    requirements contained in this section on file with their component I supporting entity. a.   Each entity shall provide compliance data to the OEM Center.
  7. Proof of compliance for all HCP will be entered into the Health Sciences Center OEM Center database.


  1. Exceptions for individual requirements are granted for recognized medical or religious reasons according to the policy of each entity.
    1. Medical: Exceptions to required immunization(s) may be granted for certain medical contraindications under the directions of the UNM Health Sciences Center Immunization Committee. Standard criteria will be established and include severe allergy to the vaccine or components as defined by the most current recommendations of the CDC's Advisory Committee on Immunization Practices (ACIP) as published in the General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR. 2011; 60(RR07):1-45.
    2. Religious exceptions will be according to the policy of each entity.


  1. Health Sciences Center HCP employees must be in compliance with the baseline requirements preferably before patient care assignments begin or at least within 3 months of employment or appointment, with the exception being the Hepatitis B vaccine series.
  2. Non-employees (e.g., students, vendors, volunteers, etc.) must be compliant with this policy prior to assuming any duties that involve direct patient care/contact with compliance validated periodically.
  3. All Health Sciences Center HCP must be in compliance with the annual requirements in the timeframe specified by the UNM Health Sciences Center Immunization Committee.
  4. See Appendix 1 for compliance information for all vaccination and screenings. Failure to comply with any of the outlined requirements shall be subject to disciplinary action up to and including termination as outlined by each entity.

Vaccine Shortage Contingency

In the event of a vaccine shortage, vaccines will be offered to personnel based on risk to patient population cared for, job function, and risk of exposure. Priority will be given to those who provide hands-on patient care with prolonged face-to-face contact with patients and/or who have the highest risk of exposure to patients. Those who are prioritized to receive vaccine will be held to the mandatory standard. Those who are not prioritized to receive vaccine will not be held to the mandatory standard for the duration of the vaccine shortage period. Recommendations will be provided to those who do not receive the vaccine by the UNM Health Sciences Center Immunization Committee in conjunction with the institutional Infection Prevention and Control entities.


Healthcare Personnel (HCP): All employees, faculty, residents, fellows, temporary workers, trainees, volunteers, students, vendors, and health care providers who provide services or work in patient care or clinical care areas. For the purposes of this policy, HCP includes others traditionally considered "non-clinical" but who fulfill the above criteria. See Appendix 2 for examples of HCP. All such persons are covered by this policy.

UNM Health Sciences Center Immunization Committee: Representatives of the Occupational and Environmental Medicine (OEM) Center programs, Infection Prevention and Control (IPCD), and associated academic colleges and Health System entities as designated by the Medical Director, Occupational and Environmental Medicine Center. See Appendix 3 for the membership.

Patient care or clinical care area: These include the licensed and/or accredited patient care areas as well as any other physical or recognized borders of inpatient and outpatient areas where patients may be seen, evaluated, treated, or wait to be seen. This applies to ambulatory facilities and any other operations buildings if patients are present. Each Health System Entity will list in their written policy their patient care and clinical care locations.

Patient: an individual undergoing medical assessment or active treatment.

BCG or Bacille Calmette-Guerin: a vaccine for Tuberculosis (TB) disease used in many countries with a high prevalence of TB.

Visitor: any person visiting or accompanying a person (patient) or visiting department/departmental contact for unofficial/official business within the Health System.


Dr. Paul Roth (HSC Chancellor and Dean of UNM School of Medicine), Dr. Michael Richards (Executive Physician in Chief), and Mr. Steve McKernan (CEO UNMH/COO of UNM Health System) will ensure adherence to this policy.

Resources and Training

Resource / DepartmenteMail Address
Marsha Houck, Unit Director, Occupational Health Services
Meghan Brett, Hospital Epidemiologist, UNMH
Denece Kesler, Medical Director, OEM Center