Berkshire Community College - Immunization Requirements Template Page 2
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2IMMUNIZATION HISTORY FOR FOREIGN-BORN STUDENTS
Name ____________________________________________________________________________________
Please Print:
Last
First
Middle Initial
BCC ID#__________________________________
Date of Birth ____ / ____ / ________
Home Address _____________________________________________________________________________
Street
_________________________________________________________________________________________
City
State
Zip
Email Address __________________________________
TITER PROOF *
Tdap VACCINE
Measles
Tetanus/Diphtheria/ Pertussis
MMR #1
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
mm
dd
yy
mm
dd
yy
mm
dd
yy
Mumps
or Td Tetanus Diphtheria
____ / ____ / _____
within the last
mm
dd
yy
MMR #2
five (5) years
____ / ____ / _____
Rubella
____ / ____ / _____
mm
dd
yy
____ / ____ / _____
mm
dd
yy
mm
dd
yy
HEPATITIS B
#1
#2
#3
Booster
Titer**
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
mm
dd
yy
mm
dd
yy
mm
dd
yy
mm
dd
yy
mm
dd
yy
VARICELLA (CHICKEN POX)
Medical Proof of Disease
Vaccine #1
Vaccine #2
Titer Immune**
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
mm
dd
yy
mm
dd
yy
mm
dd
yy
mm
dd
yy
TUBERCULOSIS TEST
Date Planted
Date Read
Chest X-ray Date (If test is positive)
____ / ____ / _____
____ / ____ / _____
____ / ____ / _____
______________________________
Result
mm
dd
yy
mm
dd
yy
mm
dd
yy
Result _________________________________________
If positive, treatment schedule _____________________________________
____ / ____ / _____
REQUESTED, NOT REQUIRED, TO COMPLETE IMMUNIZATION HISTORY:
MENINGOCOCCAL VACCINE
mm
dd
yy
*
Antibody laboratory blood tests (Titer) must include laboratory report proof of immunity. Medical forms from
doctor’s offices should include vaccinations in the English language. Immunization vaccine dates should be
complete with month, day, and year.
Medical Professional’s Signature
Date
Medical Professional’s Printed Name and Address
Please mail or fax completed form to: Immunization Records Office, Berkshire Community College,
1350 West Street, Pittsfield, MA 01201-5786. Telephone: 413-236-1614 or Fax 413-499-4576.
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