Mandatory Immunization Health History Form (Page 2 of 2) in pdf

Mandatory Immunization Health History Form - Please Follow These Directions

Basic Instructions: DO NOT WAIT! Late, incomplete or inaccurate information may delay registration.

Include the student’s ID on all correspondence. Print all student information legibly (name, phone, etc.).

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Have a doctor’s office, clinic or health department fill out the medical areas of the form. An “official stamp” AND an official

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signature from one of these entities must be included for this document to be complete and approved.

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MINORS (students under 18): A parent/guardian signature must be included for waivers.

KEEP A COPY FOR YOUR RECORDS. Should anything be amiss, you can easily refer to what was sent.

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Fax only the single records page (and lab reports as needed)

at least three (3) weeks prior to orientation/registration.

Visit the admitting school’s website for more information about admissions and immunization requirements.

Florida Agricultural and

Florida State University

University of South Florida

Mechanical University

Fax: (850) 644-8958

Sarasota Campus

Fax: (850) 599-3067

Tampa Campus

New College of Florida

Student Services – Immunization

4202 East Fowler Avenue

Florida Atlantic University

8350 N. Tamiami Trail C107

SHS100

Fax: (941) 487-4256 University

Sarasota, FL 34243

Tampa, FL 33620‐6750

Fax: (561) 297-2769

of Central Florida

Phone: (941) 359‐4330

Phone: (813) 974‐4056

Fax: (941)

359-4236

Fax: (813) 974‐5888

Florida Gulf Coast

immunization@sar.usf.edu

Fax: (407) 823-3135

immunization@shs.usf.edu

University

University of Florida

St. Petersburg Campus

Fax: (239) 590-7968

Lakeland Campus

Records and Registration

3433 Winter Lake Road –

Florida International

Fax: (352) 392-0938

DSO, International Students

Student Affairs

University

140 Seventh Avenue South, BAY 102

University of North Florida

Lakeland, FL 33803

St Petersburg, FL 33701

Phone: (863) 667‐7000

Phone: (727) 873‐4361

Miami

Fax: (904) 620-2901

Fax: (863) 667‐7096

– Fax: (305) 348-3336

Fax: (727) 873‐4FAX

University of West Florida

immunization@poly.usf.edu

morin@mail.usf.edu

North Miami

– Fax: (305) 919-5312

Fax: (850) 857-6100

Section A: Information about Required Immunizations

MMR Vaccine – Required for EVERYONE born after Dec. 31, 1956. This combination vaccine is often given because it protects from measles,

mumps and rubella. Two doses are required for entry into the state university system of Florida. One must have been received at 12 months age or later

and in 1971 or later. The second dose must have been received at least 30 days after the first dose and in 1990 or later. If you do a laboratory test to

verify immunity to measles, mumps or rubella, you must submit a copy of the laboratory report.

Hepatitis B Vaccine – You are encouraged to receive this vaccine series. Students in many academic health programs are required to have this vaccine.

Students wishing to decline this vaccine must read the information about Hepatitis B (available at ), then check and sign

where indicated on the medical records form. Signing the waiver indicates you understand the possible risk in not receiving this vaccine. If you are

under the age of 18 and wish to decline this vaccine, a parent must sign for you.

Menactra/MCV4 (Meningococcal Meningitis Vaccine) – The Advisory Committee on Immunization Practices (ACIP) currently recommends this

vaccine for freshmen planning to live in campus dormitories/residence halls. This is a requirement for all students who will live on the USF campus.

No student will be assigned a USF residence hall room until proof of meningitis vaccination is received by USF Student Health. Students not living on

campus, wishing to decline this vaccine, must read the information about Menactra/Meningococcal Meningitis (available at

), then check and sign where indicated on the medical records form. Signing the waiver indicates you understand the

possible risk in not receiving this vaccine. If you are under 18 and wish to decline this vaccine, a parent must sign for you.

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 and Most Academic Health Programs – A Tuberculosis Skin Test by PPD or Mantoux (within the last six months) is required for

international students and most academic health programs.

NOTE: If both PPD and MMR are given, they must be given on the same day for the PPD to

be accurate or given 30 days apart. PPDs must be read between 48-72 hours of administration. The result must be listed in “mm” and indicated whether

negative or positive in the space indicated. If the PPD is positive, submit a copy of the chest X-ray report done on or after PPD placement. If you do

the blood test—Interferon-based Assay (QFT or Tspot)—submit a copy of the laboratory report. If the PPD is positive or the Interferon-based

Assay is positive, submit a copy of the chest X-ray report.

Section B: Information about Recommended Immunizations for Good Health

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Td (Tetanus)/Diphtheria or/and Tdap (Tetanus/Diphtheria/Pertussis) – Booster shot within last 10 years. Space is provided to record this information.

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Varicella (Chicken pox) – History of disease or vaccine is acceptable. Indicate the date you had chicken pox. OR: Provide proof of two doses of

Varivax. OR: Provide results of a blood test on a laboratory form.

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Hepatitis A, HPV, Polio, Typhoid, Yellow Fever, Other – In the boxes provided in this section you may also list any additional vaccines that were

administered. These are not required.