Health Services Immunization Form
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1
2Return this form to: Immunization Department - UCF Health Services
HEALTH SERVICES
P.O. Box 163333, Orlando, FL 32816-3333
IMMUNIZATION FORM
or by FAX: (407) 823-3135
REQUIRED: DOCUMENTATION OF MEASLES AND RUBELLA
____________-_____________-_______________
IMMUNIZATION OR LAB EVIDENCE OF IMMUNITY
.
(If student is born prior to 1957, no vaccination documentation is required to accompany this form.)
SOCIAL SECURITY NUMBER
All students born after 1956 must have received either:
1.
Two doses of MMR; or
IMPORTANT!
2.
Two doses of measles immunization plus one dose of rubella immunization; or
COMPLETION OF THIS FORM IS NECESSARY TO COMPLY WITH FLORIDA
3.
Lab test proof of immunity to both measles and rubella (IGG blood titer).
ADMINISTRATIVE CODE 6C-6.001(4). YOUR REGISTRATION CANNOT
PROCEED WITHOUT COMPLETION OF THIS FORM.
ALL DOCUMENTATION MUST INCLUDE THE SIGNATURE
AND THE OFFICE STAMP OF THE HEALTH CARE PROVIDER.
___________________
_________
______________________________________
MMR Combined (Measles, Mumps and Rubella): Two doses required
Last Name
First Name
Middle Name
st
_______________________________________________________________________________________
______ / ______ / ______
1
dose received after 12 months of age in 1968 or later.
Street Address
Month
Day
Year
nd
st
_____________________________________
__________________________
___________________
______ / ______ / ______
2
dose received 30 days or more after the 1
dose.
City
State
Zip Code
Month
Day
Year
(OR)
_____________________________________
__________________________
___________________
Phone Number
Birthdate
Age
MEASLES (Rubeola): Two doses required
Please circle: MALE
FEMALE
st
______ / ______ / ______
1
dose received after 12 months of age in 1968 or later.
For which term are you applying?
SPRING
SUMMER
FALL
Year: _______________
Month
Day
Year
nd
st
______ / ______ / ______
2
dose received 30 days or more after the 1
dose.
Are you an international student on an F1, F2, J1 or J2 Visa?
YES
NO (please circle)
Month
Day
Year
OR
Do you have any significant, on-going health problems or concerns of which you
want Health Services to be aware? YES
NO (please circle)
______ / ______ / ______
Positive Blood IGG Titer (Lab results MUST be attached).
Month
Day
Year
If yes, please comment
: ____________________________________________________
~~~~ (AND) ~~~~
If you wish to receive care for the above problem(s) at UCF Health Center, it is
your responsibility to provide copies of pertinent medical records as necessary.
RUBELLA (German Measles): One dose required
A complete health history will be obtained at the time of your first visit.
st
______ / ______ / ______
1
dose received after 12 months of age in 1968 or later.
Month
Day
Year
STUDENT SIGNATURE _____________________ DATE _____________
OR
Medical Consent if Under 18 Years Old
______ / ______ / ______
Positive Blood IGG Titer (Lab results MUST be attached).
Month
Day
Year
I HEREBY AUTHORIZE the UCF Health Center to employ diagnostic procedures and to render any
treatment or medical, surgical, psychological, or psychiatric care deemed necessary to the health and well
being of my child. I grant permission for the transfer of my child to an accredited hospital or other care
________________________
facility if deemed necessary by the medical or mental health provider.
Physician Office
PHYSICIAN SIGNATURE
Address Stamp
Signature of Parent or Guardian: __________________________________ Date ________________
REQUIRED:
________________________
DATE
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