Recommended Immunizations - University Of Wyoming printable pdf download

STUDENT IMMUNIZATION FORM

Student Health Service  Dept. 3068  1000 E. University Ave.  Laramie, WY 82071

(307) 766-2130  fax (307) 766-2711  TTY (307) 766-2132  e-mail: studenthealth@uwyo.edu

In order to register for classes, the first section (REQUIRED IMMUNIZATION- MMR) of this Student Immunization Form must be

completed, signed and returned (mail, fax or email) to the University of Wyoming Student Health Service. Alternatively, you can

mail, fax or email a verified (signed and dated by a medical provider or a school official if using a transcript) copy of an

immunization record to the Student Health Service. All information is confidential and will become part of your medical record.

Contact the Student Health Service if you have questions regarding completion of this form.

If your MMR immunization information is incomplete, your registration process will be delayed.

Name_______________________________________________________________________________________________________

Last

First

Middle

Phone Number

Date of Birth_____________________________ W#____________________________

Permanent Address____________________________________________________________________________________________

Street address/P.O.Box

City, State, Zip code, Country (if not USA)

REQUIRED IMMUNIZATION – MMR

The University of Wyoming requires each incoming student born on or after 1/1/57 to be protected against measles, mumps, and

rubella. Compliance with this requirement is in one of three ways, as follows (check appropriate line)

_____1. Born PRIOR to January 1, 1957

_____2. Receipt of 2 MMR vaccinations REQUIRES SIGNATURE OF MEDICAL PROVIDER (at bottom of this page)

MMR #1__________(date) Must be at 12-15 months of age or later

MMR #2__________(date) Usually at age 4-6 years old or older, and at least one month after 1

dose

_____3. Blood tests of immunity to measles, mumps, and rubella (attach copy of test results)

Exemption to the required immunization may be granted for medical or religious reasons. If an outbreak of any of these three

illnesses occurs on the UW campus, students with exemptions will be excluded from campus for the duration of the outbreak. For the

forms for an exemption, please see the Student Health Service website ( ).

RECOMMENDED IMMUNIZATIONS

The following immunizations are recommended to lessen the risk of certain contagious diseases. All (except the Varicella vaccine)

are available at the Student Health Service for a nominal charge.

_______TETANUS-DIPHTHERIA (primary series plus booster)

Primary series with DTaP or DTP__________#1__________#2__________#3__________#4__________#5 (dates)

Tetanus-diphtheria booster (circle Td or TdaP) within past 10 years __________booster #1__________booster #2 (dates)

_______VARICELLA (chicken pox; history of illness, positive blood test for immunity, or two doses of vaccine)

__________History of disease (chickenpox) (date)

__________Blood test showing immunity (date; attach copy of results)

__________dose #1__________dose#2 (dates)

_______HEPATITIS B (3 shot series, or positive blood test for disease

__________dose#1__________dose#2__________dose#3 (dates)

__________Blood test showing immunity (Hep B SAb; date; attach copy of results)

_______POLIO ( primary series in childhood)

OPV 4 doses

__________dose#1__________dose#2__________dose#3__________dose#4 (dates)

IPV four doses

__________dose#1__________dose#2__________dose#3__________dose#4 (dates)

_______MENINGOCOCCAL CONJUGATE VACCINE (two doses, one at age 11-12 and booster dose at age 16)

__________dose#1__________booster dose (dates)

_______HUMAN PAPILLOMA VIRUS (three doses of the vaccine)

__________Gardasil__________Cervarix

__________dose#1__________dose#2__________dose#3 (dates)

Signature of a medical provider

Date

4/13

Recommended Immunizations - University Of Wyoming

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