Certificate Of Immunization Form printable pdf download

CERTIFICATE OF IMMUNIZATION

Gainesville College

A Two-Year Unit of the University System of Georgia

ATTENTION – The Gainesville College Admissions Office must receive this completed and signed form before admission will be granted. Upon

completion, please return to: Admissions Office, Gainesville College, P.O. Box 1358, Gainesville, GA 30505

PART A - To be completed by student

Name

LAST

FIRST

MIDDLE INITIAL

Date of Birth

Social Security #

Address

STREET

CITY

STATE

ZIP

Expected Semester and year of Enrollment

Semester

Year

PART B - To be completed and signed by a health care provider. Dates must include month and year.

Required Immunizations:

1. For students born in or before 1957, Rubella immunity, as in IV.

2. For all other students, either MMR immunity, as in I or measles, mumps and rubella immunity, as in II, III and IV.

I. MMR (Measles, Mumps, Rubella) Note: Date must be after 1970

1. ¨ Dose 1 - immunized at 12 months of age or later, and

(MO/DAY/YR)

2. ¨ Dose 2 - immunized at least 30 days after Dose 1.

(MO/DAY/YR)

II. MEASLES Note: Date must be after March 4, 1963

1. ¨ Had disease, confirmed by physician diagnosis in office record, OR

(MO/DAY/YR)

2. ¨ Born in or before 1957 and therefore considered immune, OR

(MO/DAY/YR)

3. ¨ Has laboratory evidence of immune titer (specify date of titer), OR

(MO/DAY/YR)

4. ¨ Immunized with live measles vaccine at 12 mos. of age or later, AND

(MO/DAY/YR)

5. ¨ Immunized with second dose of live measles vaccine at least 30 days

after first dose

(MO/DAY/YR)

III. MUMPS Note: Date must be after April 22, 1971

1. ¨ Had disease, confirmed by physician diagnosis in office record, OR

(MO/DAY/YR)

2. ¨ Born in or before 1957 and therefore considered immune, OR

(MO/DAY/YR)

3. ¨ Has laboratory evidence of immune titer (specify date of titer), OR

(MO/DAY/YR)

4. ¨ Immunized with vaccine at 12 mos. of age or later

(MO/DAY/YR)

IV. RUBELLA Note: Date must be after June 9, 1969

1. ¨ Has laboratory evidence of immune titer (specify date of titer), OR

(MO/DAY/YR)

2. ¨ Immunized with vaccine at 12 mos. of age or later

(MO/DAY/YR)

¨ Exemption on grounds of permanent medical contraindication

¨ Exemption on grounds of temporary medical contraindication

a) ¨ pregnancy - expected date of confinement

(MO/DAY/YR)

b) ¨ other - anticipated date of end of contraindication

(MO/DAY/YR)

Immunization status indicated above is certified by:

Signature of physician or health facility official

Date

Name and address of physician or public health facility

¨ RELIGIOUS EXEMPTION

I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to

exclusion from campus in the event of an outbreak of a disease for which immunization is required.

Signature of Student (Student signature required only for religious exemption)

Date

Certificate Of Immunization Form

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