Mandatory Immunization Health History Form

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IMPORTANT! DO NOT DELAY!
This SIGNED AND COMPLETED form is required for class registration – NO EXCEPTIONS.
After completion, fax form ASAP to the admitting school. (See next page.)
State University System of Florida
Mandatory Immunization Health History Form
Name: ___________________________________ Date of Birth: _______________ USF ID: ______________________
Phone: ___________________________________ Date Study Begins: __________________________________________
Section A: Required Immunizations
***NOTE: ALL TITERS (blood tests) MUST HAVE LAB REPORT ATTACHED***
Month/Day/Year
Month/Day/Year
Month/Day/Year
OR Attach Titer
Date & Result
DO NOT WRITE HERE
1. MMR
(2 doses after 1st birthday)
2. Hepatitis B
(OR check the declination below)
DO NOT WRITE HERE
DO NOT WRITE HERE
3. Meningitis/Menactra/MCV4
at AGE 16
; if living on campus
OR OLDER
(OR check the
declination below)
I have read the
information
about Hepatitis B and decline receipt of this vaccine.
I have read the
information
about Menactra/Meningococcal Meningitis and decline receipt of this vaccine; if NOT living on a USF campus.
_________________________________ ________
______________________________________ ________________ ________
Signature of student
Date
OR
Signature of parent/guardian if student under 18
Relationship to student
Date
4. Tuberculosis Screening:
Required for all International Students and U.S. born students residing at an address outside
the U.S. at the time of application
Pos
Date Placed
MM
Neg
Date Read
(must be read 2-
TB Skin Test by PPD
(Mantoux)
3 days of date placed)
Date
Result
Interferon-based Assay
Submit copy of lab report
OR
(QFT or Tspot)
Date
Result
Chest X-ray
Submit copy of chest X-ray report
(if positive PPD or lab)
Section B (OPTIONAL): Recommended Immunizations for Good Health
Month/Day/Year
Month/Day/Year
Month/Day/Year
OR Attach Titer
Date & Result
Td (Tetanus/Diphtheria)
DO NOT WRITE HERE / DO NOT WRITE HERE / DO NOT WRITE HERE
AND/OR Tdap (Tetanus/Diphtheria/Pertussis)
DO NOT WRITE HERE / DO NOT WRITE HERE / DO NOT WRITE HERE
Varicella (Chicken Pox)
History of Disease:
Hepatitis A
HPV (Gardasil)
Polio (last date)
DO NOT WRITE HERE / DO NOT WRITE HERE / DO NOT WRITE HERE
Other:
An official stamp from a doctor’s office, clinic or health department AND an authorized signature must appear here or this form will not be
approved.
_________________________________________________ __________________________________ ________________________
Official Office Stamp Here
Physician or Authorized Signature
Date
IMPORTANT! KEEP A COPY OF THIS PAGE AND ALL LAB REPORTS FOR YOUR RECORDS.
Mail or fax only this one (1) page (and lab reports as needed) at least three (3) weeks prior to registration.

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