Return this form to: Immunization Department - UCF Health Services
P.O. Box 163333, Orlando, FL 32816-3333
or by FAX: (407) 823-3135
HEALTH SERVICES
IMMUNIZATION FORM
____________-_____________-_______________
SOCIAL SECURITY NUMBER
IMPORTANT!
COMPLETION OF THIS FORM IS NECESSARY TO COMPLY WITH FLORIDA
ADMINISTRATIVE CODE 6C-6.001(4). YOUR REGISTRATION CANNOT
PROCEED WITHOUT COMPLETION OF THIS FORM.
______________________________________
Last Name
___________________
_________
First Name
Middle Name
REQUIRED: DOCUMENTATION OF MEASLES AND RUBELLA
IMMUNIZATION OR LAB EVIDENCE OF IMMUNITY.
(If student is born prior to 1957, no vaccination documentation is required to accompany this form.)
All students born after 1956 must have received either:
1.
Two doses of MMR; or
2.
Two doses of measles immunization plus one dose of rubella immunization; or
3.
Lab test proof of immunity to both measles and rubella (IGG blood titer).
ALL DOCUMENTATION MUST INCLUDE THE SIGNATURE
AND THE OFFICE STAMP OF THE HEALTH CARE PROVIDER.
MMR Combined (Measles, Mumps and Rubella): Two doses required
_______________________________________________________________________________________
Street Address
______ / ______ / ______
Month
Day
Year
1st dose received after 12 months of age in 1968 or later.
_____________________________________
City
__________________________
State
___________________
Zip Code
______ / ______ / ______
Month
Day
Year
2nd dose received 30 days or more after the 1st dose.
_____________________________________
Phone Number
__________________________
Birthdate
___________________
Age
Please circle:
MALE
MEASLES (Rubeola): Two doses required
FEMALE
For which term are you applying?
(OR)
SPRING
SUMMER
Are you an international student on an F1, F2, J1 or J2 Visa?
FALL
YES
Year: _______________
NO (please circle)
Do you have any significant, on-going health problems or concerns of which you
want Health Services to be aware? YES NO (please circle)
If yes, please comment: ____________________________________________________
If you wish to receive care for the above problem(s) at UCF Health Center, it is
your responsibility to provide copies of pertinent medical records as necessary.
A complete health history will be obtained at the time of your first visit.
______ / ______ / ______
Month
Day
Year
______ / ______ / ______
Month
Day
Year
Medical Consent if Under 18 Years Old
I HEREBY AUTHORIZE the UCF Health Center to employ diagnostic procedures and to render any
treatment or medical, surgical, psychological, or psychiatric care deemed necessary to the health and well
being of my child. I grant permission for the transfer of my child to an accredited hospital or other care
facility if deemed necessary by the medical or mental health provider.
2nd dose received 30 days or more after the 1st dose.
OR
______ / ______ / ______
Month
Day
Year
Positive Blood IGG Titer (Lab results MUST be attached).
~~~~ (AND) ~~~~
RUBELLA (German Measles): One dose required
______ / ______ / ______
Month
Day
Year
STUDENT SIGNATURE _____________________ DATE _____________
1st dose received after 12 months of age in 1968 or later.
1st dose received after 12 months of age in 1968 or later.
OR
______ / ______ / ______
Month
Day
Year
Positive Blood IGG Titer (Lab results MUST be attached).
________________________
PHYSICIAN SIGNATURE
Signature of Parent or Guardian: __________________________________ Date ________________
________________________
DATE
Physician Office
Address Stamp
REQUIRED:
HEALTH SERVICES
IMMUNIZATION FORM
Immunization Policy:
As a prerequisite to registration, the State University System of Florida
requires all students born after December 31, 1956 to present documented
proof of immunity to Measles (Rubeola) and German Measles (Rubella).
Proof includes this form, properly completed, stamped and signed by your
qualified health care provider OR records from health departments, health
care offices or school records attached to this form.
Acceptable Proof Consists of the Following:
1. Proof of two (2) vaccinations (doses) of MEASLES received at
least 28 days apart and one vaccination of RUBELLA.
2. Vaccinations MUST have been received AFTER your first
birthday.
3. Vaccinations MUST have been received in 1968 or later.
4. Proof of immunity by way of a blood test lab result (IGG Titer).
Exemptions:
1. Students born prior to January 1, 1957 are not required to
complete the vaccination section of this form. Please complete
the student information and return to the Health Center.
2. Religious exemption (accompanied by written documentation
on church letterhead, signed by clergy).
3. Medical exemption (accompanied by specific, written
documentation on office letterhead, signed by a physician).
Temporary Deferments:
(Must be submitted on office letterhead, signed by a physician)
1. Pregnancy or possibility of pregnancy
2. Breastfeeding
3. Illness
HOUSING STUDENTS:
Once you receive the Hepatitis B & Meningitis Waiver Form, please be sure to
forward it to Housing & Residence Life Department, NOT the Health Center.
Revised:02/22/06
Please return this form to
the Health Center.
Completed forms may be faxed to (407) 823-3135.
Health Services
The UCF Health Center is located on the main campus,
Building # 127, next to Chemistry and Biological Sciences buildings.
MMR Vaccinations and IGG Titers are available (for a fee) at the
Health Center. For an appointment, call (407) 823-3850.
Questions about acceptable proof, exemptions or
temporary deferments may be directed to the
Immunization Department of
Health Services at
(407 )823-3707 or 1 (800)613-8544
www.shs.ucf.edu.
THIS FORM IS MANDATORY!
YOU WILL NOT BE ALLOWED TO REGISTER WITHOUT
PROOF OF IMMUNITY OR EXEMPTION.
FAILURE TO HAVE ALL REQUIRED DOCUMENTATION
SUBMITTED IN ADVANCE MIGHT SIGNIFICANTLY
COMPLICATE AND DELAY YOUR REGISTRATION!