Immunization Documentation Form Page 2
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1
2Name: _______________________________________________________________________
Last
First
Middle
Panther ID Number: _____________________ Birth Date: ____ / ____ / ____
SECTIONS: A, B, C THESE BOXES ARE TO BE COMPLETED BY AUTHORIZED MEDICAL PERSONNEL ONLY
REQUIRED VACCINES
(complete sections A or B & C).
MMR Combined (Measles, Mumps, and Rubella): Two doses fulfill requirements
A.
______ / ______ / ______ 1st dose (received after 12 months of age or later).
Month
Day
Year
nd
st
______ / _______ / ______ 2
dose (received at 30 days or more after 1
dose).
Month
Day
Year
or
B. Measles (Rubeola): Two doses required
______ / ______ / ______
dose (received after 12 months of age in 1969 or later).
1
st
Month
Day
Year
nd
st
______ / ______ / ______ 2
dose (received at 30 days or more after the 1
dose).
Month
Day
Year
or
______ / _______ / ______ Positive Blood Titer (Lab results must be attached).
Month
Day
Year
----------------------------------------------------AND--------------------------------------------
----------
Rubella (German Measles): One dose required
C.
st
______ / ______ / ______ 1
dose (received after 12 months of age and in 1969 or later).
Month
Day
Year
or
______ / ______ / ______ Positive Blood Titer (Lab results must be attached).
Month
Day
Year
__________________________________
_______________________
Health Care Provider
Date
Physician /ARNP/RN Signature
Office Stamp Required:
Please submit this completed form at least four weeks prior to registration to:
Florida International University, University Health Services
University Park Campus
Biscayne Bay Campus
UHSC-Room 101
Health Care Center
11200 S.W. 8 Street
or
3000 N.E. 151 Street
Miami, FL 33199
North Miami, FL 33181
305-348-3336(FAX)
305-919-5312(FAX)
305-348-2401
305-919-5675
11/16/2004
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