Immunization Record Form
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1Immunization Record Form
This form should be completed and signed by your doctor or health care provider.
Name ________________________________________________________________
(Last Name)
(First Name)
Immunization Record*
Hepatitis B Vaccine**
Dose #1 _____/_____
Dose #2 _____/_____
Dose #3 _____/_____
M
Y
M
Y
M
Y
MMR (Measles, Mumps, Rubella) Vaccine
Dose #1 _____/_____
Dose #2 _____/_____
M
Y
M
Y
Tetanus-Diphtheria Vaccine
Dose #1 _____/_____
Dose #2 _____/_____
Dose #3 _____/_____
M
Y
M
Y
M
Y
Td booster (within the last ten years) _____/_____
M
Y
Varicella Vaccine or History of Chickenpox
a. History of Disease
_____Yes
_____No
b. Vaccine (if no history of disease)
Dose #1 _____/_____
Dose #2 (if applicable) _____/_____
M
Y
M
Y
Doctor or Health Care Provider
]
Name_____________________________ Address__________________________________________
Signature__________________________ Phone (____)________________________
* You may include a copy of your immunization record (typically it is an immunization card) if all of the
above vaccinations are documented.
** Please review the Health Related Issues Form for more information about each immunization.
***If, due to medical reasons or personal beliefs, you decide not to get these immunizations, you must sign
under “Student Life.”
an immunization waiver form, which can be found at
Return the completed form to:
Office of Student Life.
1539 E Howard St
Office Use Only:
Pasadena, CA 91104
Form received by: ________
Date received: __________
Filed by: _______
Scanned into database by: _______
Date scanned: __________
6-1-12
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Parent category: Medical