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GWU Mandatory Health Form (1)

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The George Washington University

Student Health Center (SHC)


University Student Center, Ground Floor
800 21st Street, NW | Washington, DC 20052
P: 202-994-5300 Healthcenter.gwu.edu

The Student Health Center staff extends a warm welcome to entering undergraduate students,
graduate students, non-degree students, transfer students, and parents. The District of Columbia
Immunization Law requires that all students under the age of 26 provide proof of certain
immunizations prior to registration. If you are 26 years of age or older upon entrance into the
university, you do not need to complete the Mandatory Health Form.

The required immunizations are:


1. One Tetanus Diphtheria booster or Tdap vaccine given within the last 10 years.
2. Two vaccinations against Measles, Mumps, and Rubella (MMR) given after age one and a
minimum of 28 days apart, or provide laboratory proof of immunity. All live vaccinations must
be given on the same day or minimum of 28 days apart.
3. Two vaccinations against Varicella (Chicken Pox) given after age one and a minimum of 28
days apart, or provide history of Varicella (Chicken Pox) disease, or provide laboratory proof of
immunity. All live vaccinations must be given on the same day or minimum of 28 days apart.
4. Three vaccinations against Hepatitis B, Dose 2 given 28 days after Dose 1, Dose 3 given 5
months after Dose 2, or Hepatitis B vaccination given according to ACIP/CDC guidelines or
accelerated schedule, or provide laboratory proof of immunity.
5. One Meningococcal vaccine A,C,Y,W-135* given on or after their 16th birthday, or a
signed Waiver Request Form (PDF).
6. For students under the age of 18: Four doses of IPV (inactivated poliovirus vaccine) or
provide laboratory proof of immunity.

7. All Students are required to complete a TB Questionnaire through the mySHC portal.

MMR and Varicella vaccinations are to be given on the same day or a minimum of 28 days
apart for each dose. *We strongly recommend that students planning to live in university
housing receive the Meningococcal vaccine before arriving on campus.

It is very important that you complete the enclosed Mandatory Health Form and submit it to the
Student Health Center by logging into your patient portal (myshc.gwu.edu) by the deadline. Do not
bring, fax, email these forms to the Student Health Center. If your completed form is not received
by this date, a Student Health Center hold will be placed on your account and you will not be able to
register for future semesters. Once you have completed all the requirements and submitted your form
to SHC you can log into your patient portal within 7-10 business days to check the status of your
record.

If you are under 26 years of age by June 15th (Fall entrants) by December 1st (Spring entrants)
please take the enclosed form and this letter of explanation to your health care provider to be
completed and signed. Please retain a copy of the completed form for your records. It is the
student’s responsibility to ensure that their healthcare provider completes the form and that it is
returned to the Student Health Center by the deadline.

Revised April 2023


The George Washington University
Student Health Center (SHC)
University Student Center, Ground Floor
800 21st Street, NW | Washington, DC 20052
P: 202-994-5300 Healthcenter.gwu.edu

How to Submit Your Immunization Record


In order to properly submit your immunization record, please see the following instructions:
1. Click here to access the student portal and sign-in with your GW Email Address and password.
Ensure that you are trying to log on in Google Chrome, Safari, or Firefox.
2. Click on the “Medical Clearances” tab on the left side of the screen.
3. Under “Medical Clearances” click on the green “Update” button to upload a photo or scan of your
Mandatory Health Form. Please ensure that all documents are legible.
a. Please note: If you are waiving your Meningococcal vaccination, upload the waiver form
here as well.
4. Click on each the green “Update” button next to each type of immunization and enter in the dates
of immunization. You must enter in all of your dates for the required immunizations in order for us
to verify your record.
5. Once you have updated all of your immunization dates, a staff member at SHC will review your
record.

In order to add new documentation to update your immunization record please do the following:
1. Click on the "Medical Clearances" tab.
2. Click on the green update button next to "Immunization Record". This will allow you to update
your documentation only.
3. DO NOT Click on the specific vaccination you are trying to update.
4. *Please note you cannot change previously entered information, updating your document will
prompt us to make the necessary changes to the appropriate vaccination(s).

Students seeking exemption from the immunization requirement for medical or religious reasons must
submit the GW Mandatory Health Form and a letter from a health provider or religious clergy stating
the reason for exemption along with documentation of antibody titers for Measles, Mumps, Rubella
and/or Varicella by the deadline.

If for some reason you are unable to complete the immunization requirements before arriving on
campus, the Student Health Center can assist you in meeting these requirements. Please bring your
available immunization records and the Mandatory Health Form when you visit.

Please contact immunreq@gwu.edu with any questions regarding


immunizations.

Revised April 2023


The George Washington University
Student Health Center (SHC)
University Student Center, Ground Floor
800 21st Street, NW | Washington, DC 20052
P: 202-994-5300 Healthcenter.gwu.edu

This form must be completed and uploaded to the health portal at Myhealth.gwu.edu
(Do Not Bring, Email or Fax) by June 15th for Fall entrants and by December 1st for
Spring entrants. Substitute forms will not be accepted.

DiCello Sofia G32808135


Last Name First Name GWID#

dicellosofia0@gmail.com 440-667-5871 08/09/2005 2023


E-mail Address Contact Phone Number Date of Birth (MM/DD/YYYY) Semester/Year Admitted

This form is required for all incoming students under 26 years of age as of July 1st. Please have your
healthcare provider complete, sign this form in English, and return it to SHC by uploading to the patient
portal at Myhealth.gwu.edu. Vaccination and birth dates should be written using MM/DD/YYYY. Keep
a copy of this form for your records.

Td Booster/Tdap ___/___/___
09 04 2007 Given within the last 10 years

MMR and Varicella vaccinations are to be given on the same day or a minimum of 28 days apart for each
dose.
MMR#1 ___/___/___
09 04 2007 Given after 12 months of age
MMR#2 ___/___/___
09 25 2009 Given a minimum of 28 days after MMR#1
OR, if your immunizations do not follow the required schedule, you must submit a lab report showing
positive immunity.
Varicella#1 ___/___/___
09 04 2007 Given after 12 months of age
(Chicken Pox)
Varicella#2 ___/___/___
09 25 2009 Given a minimum of 28 days after MMR#1
(Chicken Pox)

History of disease (Date/Age)


OR, if your immunizations do not follow the required schedule, you must submit a lab report showing
positive immunity.
Hepatitis B#1 ___/___/___
10 28 2005

Hepatitis B#2 ___/___/___


01 06 2006 Given a minimum of 28 days after Hepatitis B#1

Hepatitis B#3 ___/___/___


02 14 2006 Given a minimum of 5 months after Hepatitis B#2
OR, if your immunizations do not follow the required schedule, you are required to submit a lab report
showing positive immunity.

Meningococcal ___/___/___
06 13 2019 Given on/after 16th birthday
(Acyw135)

OR you must attach a signed Waiver Request Form (PDF)

Revised April 2023


The George Washington University
Student Health Center (SHC)
University Student Center, Ground Floor
800 21st Street, NW | Washington, DC 20052
P: 202-994-5300 Healthcenter.gwu.edu

Polio for students younger than 18 as of 7/1/2023 for Fall Entrants or 12/1/2023 for Spring Entrants
IPV#1 ___/___/___ Given between 6-8 weeks of age

IPV#2 ___/___/___ Given at 4 months (at least 4 weeks after dose 1)

IPV#3 ___/___/___ Given at 6-18 months (at least 4 weeks after dose 2)

IPV#4 ___/___/___ Given 4-6 years (at least 6 months after dose 3)
OR, if your immunizations do not follow the required schedule, you must submit a lab report showing
positive immunity.

Exemptions
Students seeking a medical or religious exemption for any of the above immunizations
must follow the instructions found at https://healthcenter.gwu.edu/immunizations.

Medical exemptions must be accompanied by a letter from a medical provider supporting the
exemption. Must include copies of MMR and Varicella Antibody Titers

Religious exemption is considered if the responsible person objects in good faith and in writing that the
immunizations violate their religious beliefs. The letter should be addressed to the
President of George Washington University as the head of the institution. Must include copies of MMR
and Varicella Antibody Titers

Healthcare Provider Signature or Stamp:

Date:

Healthcare Provider Phone Number:

Revised April 2023

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