Certificate Of Immunization Form

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Certificate of
QUESTIONS?
RETURN TO:
Oberlin College
440-775-8180 or
Student Health Services
student.health@oberlin.edu
Immunization
247 W. Lorain St., Suite A
(e-mail preferred)
Oberlin, OH 44074
Or fax to: 440-775-6404
Or e-mail: student.health@oberlin.edu
 Required of all students
(Page 1 of 5)
Immunization Requirements can be found at
Deadline June 15, 2016
The information you provide on this form is strictly for the use of Student Health Services and the Sports Medicine Department and
will not be released to anyone without your knowledge and consent. All full-time students and others utilizing the services of
Student Health Services must complete this form. Enrollment will be delayed until all required sections of this form are completed.
The only circumstances under which a student may be exempt from the required immunizations listed on this form are as follows:
• Certification in writing by an examining physician who is of the opinion that the physical condition is such that health would
be endangered by one or more of the immunizations. The student will be required to submit laboratory evidence of immunity to
measles, mumps, and rubella, and if not immune, will have to leave campus in the event of an outbreak.
or
• The student states in writing that the required immunizations would conflict with his or her religious beliefs. The student will
be required to submit laboratory evidence of immunity to measles, mumps, and rubella, and if not immune, will have to leave
campus in the event of an outbreak.
Name:
Date of Birth:
________________________________________________________________
___________________________________
Last
First
Middle
Month/Date/Year
REQUIRED IMMUNIZATIONS
A. MMR (Measles, Mumps, Rubella). Two live immunizations required on or after the first birthday, at least 30 days apart.
1. Dose 1 ___/___/___
2. Dose 2 ___/___/___
mo. day
yr.
mo. day
yr.
A positive serological test for immunity to any of the above diseases is acceptable instead of immunizations.
A history of disease is not acceptable.
Positive MEASLES titer: ___/___/___
Positive MUMPS titer: ___/___/___
Positive RUBELLA titer: ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
B. Tetanus-Diphtheria
1. Primary series DTaP or DTP: ___/___/___
2. ___/___/___
3. ___/___/___
4. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
mo. day
yr.
2. Td booster (within last 10 years): ___/___/___
or Tdap: ___/___/___
mo. day
yr.
mo. day
yr.
C. Polio
1. Primary series (minimum three dates required):
OPV (oral)
IPV (injected): 1. ___/___/___
2. ___/___/___
3. ___/___/___
4. ___/___/___
mo. day
yr.
mo. day
yr.
mo. day
yr.
mo. day
yr.

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