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    Immunization Requirement 060408

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    xcygon
    This document outlines mandatory immunization requirements for students at a university. It requires students to provide dates for immunizations including two MMR vaccines, three doses of Hepatitis B vaccine, a meningitis vaccine, a tuberculosis skin test within the last year, and a tetanus/diphtheria vaccine within the last 10 years. It collects the student's name, address, and date of birth and requires a health professional's signature and contact information to verify the immunization dates.

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    Immunization Requirement 060408

    Uploaded by

    xcygon
    36 views2 pages
    This document outlines mandatory immunization requirements for students at a university. It requires students to provide dates for immunizations including two MMR vaccines, three doses of Hepatitis B vaccine, a meningitis vaccine, a tuberculosis skin test within the last year, and a tetanus/diphtheria vaccine within the last 10 years. It collects the student's name, address, and date of birth and requires a health professional's signature and contact information to verify the immunization dates.

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    This document outlines mandatory immunization requirements for students at a university. It requires students to provide dates for immunizations including two MMR vaccines, three doses of Hepatitis B vaccine, a meningitis vaccine, a tuberculosis skin test within the last year, and a tetanus/diphtheria vaccine within the last 10 years. It collects the student's name, address, and date of birth and requires a health professional's signature and contact information to verify the immunization dates.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    36 views2 pages

    Immunization Requirement 060408

    Uploaded by

    xcygon
    This document outlines mandatory immunization requirements for students at a university. It requires students to provide dates for immunizations including two MMR vaccines, three doses of Hepatitis B vaccine, a meningitis vaccine, a tuberculosis skin test within the last year, and a tetanus/diphtheria vaccine within the last 10 years. It collects the student's name, address, and date of birth and requires a health professional's signature and contact information to verify the immunization dates.

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    of 2

    Submit To: Student Health Services

    Estelle & Zoom Fleischer Athletic Center


    323 Martin Luther King Blvd., Newark, NJ 07102
    Office #973-596-3621 – Fax #973-596-0047

    MANDATORY IMMUNIZATION REQUIREMENTS


    Keep A Copy Of Your Immunization Records

    Name: ________________________________________________________________________________
    (Please Print)
    Address: ______________________________________________________________________________

    Social Security or I.D. # ______________________________Date of Birth:_________________________


    Month/Day/Year

    1. Measles, Mumps, and Rubella


    Two MMR’S are required ON OR AFTER 12 months of age. The second MMR vaccine must be 30
    days after the first vaccine). Please write dates as month/day/year.

    a. Measles, Mumps, and Rubella – Two MMR’s are required on or after 12 month of age. The second
    MMR vaccine must be 30 days after the first vaccine.

    MMR Vaccine 1: ___________ Measles Vaccine 1: ________ Mumps Vaccine 1: __________


    Date Date Date
    MMR Vaccine 2: ___________ Rubella Vaccine 1: _________
    Date Date

    b. Or attach Lab report showing serology blood test IgG levels for measles, mumps, and
    Rubella. (If any results are Negative/Non-immune, vaccination is required)

    2. Hepatitis B Vaccine: Date 1: ___________Date 2: __________ Date 3: ___________


    Health care provider, please note: ( if given 2 dose regiment, please include name of vaccine given)
    Or attach lab report showing evidence of immunity

    3. Meningitis Vaccine for types A, C, Y, W 135 incoming students residing in on-campus housing

    Menactra (Preferrable) Date: ______________ or Menomune Date: ____________

    4. Tuberculosis Skin Test (within 12 months of registration , required regardless of BCG)

    Date Applied: __________ Date Read: ___________ Size of induration __________mm


    (If you tested positive or in the past have had a positive, provide a copy of the Chest x-ray report)

    Recommended Immunizations

    Tetanus/Diptheria (within 10 years) Date: _________ Tdap Date: ____________

    Health Professional Signature: _____________________________________ Date:___________________

    Address: _________________________________________________Phone #:______________________


    (Please affix office stamp to the document)

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