MANDATORY IMMUNIZATION FORM
ALL FIRST-TIME ENTERING STUDENTS BORN AFTER 1956
MUST PROVIDE PROOF OF ADEQUATE IMMUNIZATION
AGAINST MEASLES, MUMPS & RUBELLA (MMR) AND COMPLETE A TUBERCULOSIS
QUESTIONNAIRE
ALL STUDENTS LIVING IN UNIVERSITY HOUSING AND THE GROVE ARE REQUIRED TO
HAVE THE MENINGITIS VACCINE
University of South Alabama Student Health Center
650 Clinic Drive Suite 1200 Mobile, AL 36688
(251) 460-7151/ FAX (251) 414-8227
**For more information go to http://www.southalabama.edu/studenthealth for more information.** **For more information go to
http://www.southalabama.edu/studenthealth for more information
EMAIL RECORDS TO: immunizations@southalabama.edu
Vaccine/Type
Required
Date Administered
Vaccine/Type
Date Administered
Measles (Rubeola)
German Measles (Rubella)
Mumps
MMR
Meningococal (within last 5 yrs)
In lieu of above:
Positive titer date (Rubeola) ___/___/___
Positive titer date (Rubella) ___/___/___
Positive titer date (Mumps) ___/___/___
****** (OPTIONAL) ****** (OPTIONAL) ****** (OPTIONAL) ****** (OPTIONAL) ******
*Tetanus___/___/___
TDAP___/___/___
Varicella___/___/___
HPV___/___/___
___/___/___
___/___/___
*A tetanus booster or basic series within the past 6 years is recommended.
Hepatitis B (3 shots)___/___/___
1st
2nd
Physician or Authorized Signature
___/___/___
3rd
___/___/___
Date
License # or Office Stamp
Please have your health care provider complete and sign or attach documents verifying that you have completed required screening and immunizations.
Failure to provide the immunization record prior to the beginning of class may impact the enrollment status.
Name:
Student #:
DOB:
THESE TESTS WILL ALSO BE AVAILABLE AT STUDENT HEALTH DURING ORIENTATION.