IMMUNIZATION VERIFICATION FORM
PRINT STUDENT NAME [LAST, FIRST, MI]
DATE OF BIRTH [MM/DD/YYYY]
UNIVERSITY HEALTH SERVICES
126 STUDENT HEALTH CENTER
UNIVERSITY PARK, PA 16802
PHONE (814) 863-1975
FAX (814) 865-9309
PENN STATE ID NUMBER
GENERAL INSTRUCTIONS: This form is due by September 15 for Fall Students, July 15 for Summer students and January 15
for Spring students. Students born in 1956 or before are considered immune and are exempt from the MMR requirement.
Failure to comply with the requirements will prevent the student’s enrollment for the next semester.
FOR THE SAFETY OF OUR CAMPUS COMMUNITY, STUDENTS WHO DO NOT PROVIDE APPROPRIATE EVIDENCE OF
IMMUNITY MAY BE REMOVED FROM CAMPUS DURING A COMMUNICABLE DISEASE OUTBREAK.
HEALTHCARE PROVIDER INSTRUCTIONS: Please complete this form and provide a copy of all original immunization
records including any childhood immunization records or blood test showing immunity.
MMR REQUIREMENT: [For all degree seeking students] 2 doses of Measles (Rubeola), 2 doses of Mumps and 1
dose Rubella vaccine after first birthday OR 2 doses of MMR after first birthday OR Positive (reactive) MMR titers
confirming immunity. Dose 2 must have been given at least 4 weeks after dose 1.
1. Measles-Mumps-Rubella (MMR) Vaccines:
Date for Dose 1: ___________________ Date for Dose 2: ___________________
-ORIndividual Measles, Mumps, Rubella Vaccines:
2. Date for Measles Dose 1: ___________________ Date for Measles (Rubeola) Dose 2: ___________________
3.
Date for Mumps Dose 1: ___________________ Date for Mumps Dose 2: ___________________
4.
Date for Rubella Dose 1: ___________________
-ORMMR Titers [Equivocal results are not accepted. Results must be Positive or Negative and accompanied by a copy
of blood test results. Please note that only positive (reactive) titers satisfy this requirement.]
5.
Date for Measles Titer Confirming Immunity: ___________________ Result (circle one): Positive
Negative
6.
Date for Mumps Titer Confirming Immunity: ___________________ Result (circle one): Positive
Negative
7.
Date for Rubella Titer Confirming Immunity: ___________________ Result (circle one): Positive
Negative
8. HOUSING MENINGOCOCCAL VACCINE REQUIREMENT: One dose of Meningococcal serogroups A, C, W and Y on
or after 16th birthday is required for students living in University Housing. Common U.S. names for this vaccine
are Menveo and Menactra.
Date for last Meningococcal vaccine: ___________________
The following immunizations are strongly recommended:
9. BEXSERO Meningococcal B Vaccine: Serogroup B
Date for Dose 1: ___________________ Date for Dose 2: ___________________
-OR10. TRUMENBA Meningococcal B Vaccine: Serogroup B [Can be given in a 2 or 3 dose schedule]
Date for Dose 1: _______________ Date for Dose 2: _________________ Date for Dose 3: __________________
IMMUNIZATION VERIFICATION FORM
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IMMUNIZATION VERIFICATION FORM
PRINT STUDENT NAME [LAST, FIRST, MI]
DATE OF BIRTH [MM/DD/YYYY]
UNIVERSITY HEALTH SERVICES
126 STUDENT HEALTH CENTER
UNIVERSITY PARK, PA 16802
PHONE (814) 863-1975
FAX (814) 865-9309
PENN STATE ID NUMBER
11. Varicella (Chickenpox) Vaccine:
Date for Dose 1: ___________________ Date for Dose 2: ___________________
-OR12. Varicella (Chickenpox) Titer - If you have had chickenpox, an antibody titer test can be performed to confirm
immunity to the disease. [Equivocal results are not accepted. Results must be Positive or Negative and
accompanied by a copy of blood test results. Only positive (reactive) titers confirm immunity.]:
Date for Varicella Titer: ___________________
Result (circle one):
Positive
Negative
13. Tdap (tetanus, diphtheria, and pertussis) Vaccine [this is not the same as DTap]:
Date of last Tdap Dose: ____________________
14. Td (tetanus, diphtheria) Vaccine:
Date of last Td Dose: ______________________
15. Hepatitis B (Hep B) Vaccine:
Date for Dose 1: ___________________ Date for Dose 2: __________________ Date for Dose 3: ________________
16. Hepatitis A (Hep A) Vaccine:
Date for Dose 1: ___________________ Date for Dose 2: __________________
Date for Dose 3 (if combined vaccine given): ___________________
17. CERVARIX Human Papilloma (HPV) Vaccine:
Date for Dose 1: ___________________ Date for Dose 2: __________________ Date for Dose 3: ________________
-OR18. GARDASIL Human Papilloma (HPV) Vaccine:
Date for Dose 1: ___________________ Date for Dose 2: __________________ Date for Dose 3: ________________
-OR19. GARDASIL-9 Human Papilloma (HPV) Vaccine:
Date for Dose 1: ___________________ Date for Dose 2: __________________ Date for Dose 3: ________________
Pneumococcal is recommended for some students at an increased risk for pneumococcal disease.
20. Pneumococcal Vaccine 13-Valent:
Date for Dose 1: ___________________
21. Pneumococcal Vaccine 23-Valent:
Date for Dose 1: ___________________
Healthcare Provider Name (please print)
Title:
Signature:
Phone:
Address:
Organizational Stamp
Date:
Provider: Please provide this completed form and a
copy of all original immunization records, including
any immunization blood tests showing immunity
IMMUNIZATION VERIFICATION FORM
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