Uab Student Health And Wellness Health History Form Page 3
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4UAB Student Health & Wellness Immunization Form
Non-Clinical International Students
This form is required to be submitted through . *Copies of your original immunization records will also be
accepted in place of this form (MUST be in English).
NAME: ___________________________________________________________ DATE OF BIRTH: (mm/dd/yyyy): _______________
ADDRESS: ___________________________________________________________________ PHONE: _________________________
PROGRAM OF STUDY: ________________________________________________BLAZERID:_______________________@UAB.EDU
IMMUNIZATION HISTORY MUST BE COMPLETED BY A HEALTH CARE PROVIDER
1. MMR- Measles, Mumps, and Rubella: All students must satisfy this requirement, either by two vaccine doses against each of the
three diseases or laboratory evidence of immunity to all three diseases.
EITHER
Two doses of MMR vaccine:
Date: _____/_____/_____
Date: _____/_____/_____
OR
Two doses of each vaccine component:
Measles
Date: _____/_____/_____ Date: _____/_____/_____
Mumps
Date: _____/_____/_____ Date: _____/_____/_____
Rubella
Date: _____/_____/_____ Date: _____/_____/_____
OR
Laboratory evidence of immunity to all three diseases:
Measles
Date: _____/_____/_____ Result: _______________
Mumps
Date: _____/_____/_____ Result: _______________
Rubella
Date: _____/_____/_____ Result: _______________
*If any laboratory titers are non-immune, 2 repeat vaccines are required. Date: _____/_____/_____ Date: _____/_____/_____
2. Tdap- Tetanus, Diptheria, Acellular Pertussis: All students must have had one dose within the past 10 years.
Date: _____/_____/_____
3. Varicella (chickenpox): All students must have documented history of Varicella, a positive Varicella antibody titer, or two doses
of Varicella vaccines given at least 28 days apart.
EITHER
History of Varicella (chickenpox or shingles):
Yes: _____ No: _____
Date: _____/_____/_____
OR
Varicella antibody titer
Positive: _____ Negative: _____
Date: _____/_____/_____
OR
Varicella vaccination Dose 1: _____/_____/_____
Dose 2: _____/_____/_____
*If Varicella antibody titer is negative or equivocal, two repeat vaccinations are required.
Varicella vaccination Dose 1: _____/_____/_____ Dose 2: _____/_____/_____
4. Meningococcal: All students 21 and younger are required to show documentation of a meningitis vaccine given on/after their
th
16
birthday. Students age 22 and older are exempt.
Date: _____/_____/_____
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