Health Services Immunization Record Form

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Health Services Immunization Record Form
The university requires verification of immunizations and/or serological test for Measles, Mumps and Rubella (exact dates required). If documentation is
not received by the deadline, an academic hold may be implemented. This form is to be completed by a health care provider. Please return this form to
the student when it is completed.
Student Name: _______________________________________ Preferred Name: ________________________ Date of Birth: __________________
NH Requirements/
Vaccines
Dates Given
Recommendations
MMR
2 doses for MMR
#1:
____/____/____
#2:
____/____/____
(Measles, Mumps,
Measles
Rubella), with first
Titer
dose given after 1st
#1:
____/____/____
#2:
____/____/____
date:
____/____/____
birthday; positive
Mumps
Titer
titers (include copy
#1:
____/____/____
#2:
____/____/____
date:
____/____/____
of lab work); or 2
doses Measles, 2
Rubella
Titer
doses Mumps and
#1:
____/____/____
date:
____/____/____
1 dose Rubella
Tdap/Td
Tdap/Td booster
within the last 10
Tdap:
____/____/____
Td:
____/____/____
years
Meningococcal
Recommended for
all 1st year students
living in residence
Date:
____/____/____
halls
Varicella (chicken pox)
History of illness, 2
#1:
____/____/____
#2:
____/____/____
doses of Varicella
vaccine (minimum
of 4 weeks between
OR Illness date:
____/____/____
doses), or positive
titer
OR Titer date:
____/____/____
Hepatitis B
3 doses OR positive
#1:
____/____/____
#2:
____/____/____
#3:
____/____/____
surface antibody
OR Titer date:
____/____/____
titer
DTP/DTaP Series
Series completion date:
____/____/____
Polio Series (OPV/IPV)
Series completion date:
____/____/____
HPV Series
#1:
____/____/____
#2:
____/____/____
#3:
____/____/____
TST (Tuberculin Skin
Date
Required only if at
Test) Mantoux Method
administered:
____/____/____
Results:
____ mm
high risk. Students
must complete the
Date read:
____/____/____
Tuberculosis
Chest x-ray date:
____/____/____
Include a copy of the chest x-ray.
Screening at
unh.edu/health-
services/incoming-
students to
determine risk.
History of BCG
Date:
____/____/____
Other Vaccines
Date:
____/____/____
Date:
____/____/____
Date:
____/____/____
The above-named patient is requesting exemption from the immunizations requirements/recommendations. Please provide proper documentation
supporting the exemption(s). [ ] Health [ ] Religious [ ] Other
Health care provider’s _________________________________
___________________________________
________________________
(Signature)
(Print name)
(Date)
Address: _____________________________________________________________________________ Telephone: (______)_________________

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