Mandatory Immunization Health History Form (Page 4 of 4) in pdf

Mandatory Immunization Health History Form Page 4

If you can answer “yes” to each of these checklist questions, you are ready to mail

or fax the Mandatory Immunization Health History Form:

1. Is all the information printed and legible?

2. Have I included my UCF ID number?

3. Have I listed dates for: Two MMR vaccinations?

4. Have I been immunized for Meningococcal disease? If yes, was the

vaccine given to me after the age of 16? If not, have I received a

Meningococcal booster? OR have I signed the waiver that I decline

the vaccine?

5. Have I completed the Hepatitis B series: OR signed the waiver to

decline this vaccine?

6. If I am presently under the age of 18: did my parent or guardian

sign the waivers referred to in section A AND the consent for

medical treatment in section D?

7. Has my doctor’s office or the health department officially

“stamped” the immunization form or another form verifying

immunization requirements?

8. Is there an authorized health professional’s signature in place?

So, how did you do? Please remember that if your immunization information is

incomplete or inaccurate, UCF registration may be delayed or even blocked.

Mail or FAX the one page Mandatory Immunization Health History Form (with any

attachment/s)

as soon as possible, preferably three (3) weeks prior to your scheduled orientation

session to:

UCF Health Services- HIM Department

Phone (407) 823-3707

4000 Central Florida Blvd

FAX (407) 823-3135

Orlando, FL 32816-3333

Revised 01/2013

Mandatory Immunization Health History Form Page 4