STUDENT IMMUNIZATION
HISTORY FORM
Name: __________________________________________________ School: ___________________________
N
Date of Birth: _________/_________/_________ University I.D. Number: ______________________________
MM
DD
YY
Check appropriate items and enter dates as Month/Day/Year.
For more information please visit nyu.edu/health/requirements
M.M.R. (Measles, Mumps, Rubella) If given instead of individual immunization
ose 1 Immunized on or after first birthday AND on
D
or after January 1, 1972
Dose 2 Immunized 15 months after birth or later AND
at least 28 days after first dose
_____/_____/_____
_____/_____/_____
MEASLES (RUBEOLA)
□
MM
DD
YY
MM
□
Dose 1 Immunized on or after first birthday
AND on or after January 1, 1968 MM
DD
Dose 2 Immunized 15 months after birth or later AND
at least 28 days after first dose
MM
DD
□
Dose 1 Immunized on or after first birthday
AND on or after January 1, 1968 DD
YY
Dose 2 Immunized at least 28 days after first dose
_____/_____/_____
DD
YY
YY
Has report of positive (reactive) immune titer
MUST SUBMIT COPY OF LAB REPORT
DD
YY
□
Dose 1 Immunized on or after first birthday
AND on or after January 1, 1968 AND
_____/_____/_____
Physician-diagnosed history of disease _____/_____/_____
□
DD
YY
Has report of positive (reactive) immune titer
MUST SUBMIT COPY OF LAB REPORT
_____/_____/_____
MM
RUBELLA (German Measles)
DD
□
MM
AND
_____/_____/_____
MM
DD
_____/_____/_____
MM
MM
Physician-diagnosed history of disease
YY
MUMPS
MM
□
MM
YY
_____/_____/_____
YY
_____/_____/_____
AND
_____/_____/_____
DD
□
DD
YY
Has report of positive (reactive) immune titer
MUST SUBMIT COPY OF LAB REPORT
_____/_____/_____
MM
YY
DD
YY
Dose 2 Immunized at least 28 days after first dose
_____/_____/_____
MM
DD
YY
MENINGOCOCCAL VACCINE (age 16 or after)
Immunization
Date _____/_____/_____
□
MM
□
DD
Menomune
YY
Mencevax
□
Menactra
□
Other ________________________
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TETANUS-DIPHTHERIA-PERTUSSIS VACCINE
Tetanus-Diphtheria-acellular Pertussis (Tdap)
____/____/____
MM
DD
YY
AND/OR
Tetanus-Diphtheria (Td) booster within the last ten years
____/____/____
MM
DD
YY
POLIO VACCINE
Dose 2
Dose 1
____/____/____
MM
DD
YY
Dose 3
____/____/____
MM
DD
Dose 4
____/____/____
YY
MM
DD
Dose 5
____/____/____
YY
MM
DD
____/____/____
YY
MM
DD
YY
VARICELLA (CHICKEN POX)
Immunization
Physician-diagnosed history of disease
Dose 1 ____/____/____
MM
DD
YY
____/____/____
MM
DD
YY
Varicella antibody ____/____/____
Dose 2 ____/____/____
MM
DD
Result
YY
Reactive
□
MM
DD
Non-reactive
YY
□
HEPATITIS A & B
Immunization (Hepatitis B)
Hepatitis B surface antibody
Dose 1 _____/_____/_____
_____/_____/_____
Dose 2 _____/_____/_____
Result
MM
MM
DD
DD
YY
MM
YY
DD
Reactive
Dose 3 _____/_____/_____
MM
DD
□
YY
Non-reactive
Immunization
(Combined Hepatitis A and B
Vaccine)
□
MM
DD
YY
DD
YY
Dose 3 _____/_____/_____
Dose 1 _____/_____/_____
DD
MM
Dose 2 _____/_____/_____
YY
Immunization (Hepatitis A)
MM
Dose 1 _____/_____/_____
MM
YY
DD
YY
Dose 2 _____/_____/_____
MM
DD
YY
PNEUMOCOCCAL VACCINE
PPSV23 one or two doses
Dose 1 _____/_____/_____
MM
DD
Dose 2 _____/_____/_____
MM
YY
DD
YY
MM
DD
HUMAN PAPILLOMAVIRUS (HPV) VACCINE
□
□
HPV-2
HPV-4
Dose 1 _____/_____/_____
MM
DD
YY
YY
□
HPV-9
Dose 2 _____/_____/_____
MM
DD
YY
Dose 3 _____/_____/_____
MM
DD
YY
PLEASE NOTE: This form will not be accepted if this section is not completed in its entirety.
Healthcare Provider Name (MD, DO, NP, RN):____________________________________________________________
Signature: _______________________________________________ Date: ___________________________
Healthcare Provider Stamp or Office Stamp for Address: _________________________________________
Telephone: _____________________________________________ Lic #: ____________________________
NOTE: PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS.
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