MU Immunization/TB Screening Requirements
***Please read carefully. Failure to complete as instructed may result in registration delays
Name: ___________________________________________
Student ID#: ______________
Last
First
MI
Address: ______________________________________________________________________
Phone #: ______________________________ Date of Birth: Month____ Day___ Year_____
E-Mail Address:______________________________
Instructions:
Obtain complete copies of your immunization records and attach to this form. Students
should retain original documents. Copies of records may be destroyed after entry into the
University database. Examples of acceptable documents include:
Copies of personal immunization records i.e. baby book
Copies of physician office or Health Department immunization records
Copies of high school or previous college immunization records
Part I
Measles, Mumps, Rubella
Required for all students
2 doses of MMR vaccine. The first dose must have been given at age 12 months or later. The second dose
must have been given at least one month after the first one.
OR
Titer (blood test) results proving immunity to measles, mumps and rubella. Documentation is required.
Part II
Meningococcal Vaccine
Required for students living in residence halls
Missouri legislation requires students in University owned housing to either 1) show documentation of
meningococcal vaccine received or 2) sign a waiver that indicates they have been provided educational
materials, but have chosen not to receive the vaccine at this time. To obtain the waiver for meningococcal
vaccine, the form may be downloaded and printed from:
http://www.umsystem.edu/media/fa/management/records/forms/other/um55.pdf
Part III
Tuberculosis (TB) Screening
Required for high risk students
Check any that apply: Have you ever…
____ lived for ≥ 2 months in Asia, Africa, Central or South America or Eastern Europe. Were you born in
one of these continents?
____ been a health care worker.
____ volunteered or worked in a nursing home, prison or other residential institution.
____ had contact with a person known to have active Tuberculosis.
***If none of the above applies, please check here:

A. If any of the above do apply, TB screening is required. Testing need/ method will be determined by
risk factors & may include students other than listed above. If you fall in a high risk category or have
questions regarding need for TB testing please call the Prevention desk @ (573)882-7747 or 882-4661.
OR
B. Provide documentation of TB screening (Mantoux skin test documented in millimeters of induration)
done in the U.S. within the past 12 months or prior QuantiFeron gold TB results
OR
C. Provide documentation of prior treatment for active TB disease or latent TB infection.
Pg. 2
Send immunization documents directly to the Student Health Center at the address below.
-Do not return documents to any other University department, as they are not forwarded to usStudent Health Center
-orUniversity of Missouri – Columbia
DC800.00, 1101 Hospital Drive
University Physicians Medical Building
Columbia, MO 65212
Attn: Immunization Policy
Fax to: (573) 884-8902
-or-
E-mail scanned attachments to:
immunizations@health.missouri.edu
Please send in jpg, gif or pdf format.
Additional Information
1. MMR requirement. The University of Missouri requires that all newly enrolled or readmitted MU
students born after December 31, 1956 must comply with the two-dose MMR Immunization Policy.
If a second immunization is needed, it must be the combined MMR vaccine. Students who do not
comply will not be allowed to register or pre-register for their second semester at MU.
2. Meningococcal vaccine- Must receive either MCV4 (Menactra®) or MPSV4 (Menomune®)
to meet requirement. If vaccine not received must sign waiver form. Students who do not
comply will not be allowed to register or pre-register for their second semester at MU.
3. TB screening requirements- Testing method will be determined by risk category. May
require either Tuberculin skin testing (TST) or QuantiFeron-gold TB blood testing.
Testing is recommended (but not mandated) for individuals in the following groups
because when latent TB infection is present, risk for progression to active TB disease is
very high:
 HIV positive
 Immunosuppressive disorders
 History of IV drug abuse or alcoholism
 Students with chronic medical conditions i.e. diabetes, silicosis, cancer, kidney
disease, malabsorption disorders
4. Other immunizations recommended, but not required for University students include
 Tetanus/Diphtheria administered within the past 10 years (one time booster dose
of Tetanus/ Diphtheria/ Pertussis is now recommended)
 Hepatitis B series (3 doses). Even if incomplete, provide dates of any doses
received.
 Influenza vaccine. Available each Fall -advisable for all students but in particular
those with asthma or other chronic illnesses.
 Varicella (chicken pox). No vaccine is needed if there is a good history of natural
infection. If history is questionable, a blood test can be done at the student’s expense
to determine immune status. If history of chicken pox infection, indicate approximate
date: Month__________ Year__________
If you have received any of these immunizations, please send a copy of your records.
All of the vaccines listed may be obtained at the Student Health Center and charged to the student’s
account. Call (573) 882-7481 if you wish to schedule an appointment.
Rev. 3.27.08