Certificate Of Immunization Form
ADVERTISEMENT
1
2DALTON STATE COLLEGE
UNIVERSITY SYSTEM OF GEORGIA
CERTIFICATE OF IMMUNIZATION
(EFFECTIVE SPRING SEMESTER 2005)
See the back of this form for immunization requirements and acceptable documentation. Keep a copy of the form for your records.
STUDENT INFORMATION
Social Security Number/Student ID __________________________ - __________________________ - _________________________
Name________________________________________________________________________________________________________
Last
First
Middle
Address______________________________________________________________________________________________________
City _____________________________________ State _________________________________Zip___________________________
Term of Enrollment ________________________ Age at time of application _______________ Date of Birth _____/______/_____
IMMUNIZATION INFORMATION (See the reverse of this form for specific immunization requirements)
DATE OF POSITIVE
VACCINE
DATE
DATE
DATE
DATE
LAB/SEROLOGIC
EVIDENCE
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MMR *
/
/
/
/
/
/
/
/
Measles *
/
/
/
/
/
/
/
/
/
/
Mumps *
/
/
/
/
/
/
/
/
/
/
Rubella *
/
/
/
/
/
/
/
/
/
/
(or History of varicella)
Varicella
/
/
/
/
/
/
/
/
/
/
(Chicken Pox)
Tetanus-Diptheria
(DTP,DtaP, or TD)
/
/
/
/
/
/
/
/
Type Series:
Hepatitis B **
/
/
/
/
/
/
? 2-dose series
/
/
? 3-dose series
* Not required if born before 1957.
** Only required for students who are 18 years of age or younger at time of expected matriculation.
PERMANENT OR TEMPORARY IMMUNIZATION EXEMPTION
o
This student is exempt from the above immunizations on the ground of permanent medical contraindication.
o
This student is temporarily exempt from the above immunizations until _______/________/_______.
CERTIFICATION OF HEALTH CARE PROVIDER (This information is required.)
Name_______________________________________________
Signature_____________________________________________
(Please Print)
Address______________________________________________________________________________________________________
Date of issue_________________________________________
EXEMPTIONS
Check the appropriate box, sign, and date if you are claiming exemption of the immunization requirement for the following reason:
o
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 in the event of an outbreak of a disease for which immunization is required.
Student Signature ___________________________________________________________________Date______________________________
Return this form to:
Dalton State College
213 N. College Drive
Dalton, GA 30720
Dalton State College is an Equal Opportunity Institution and is a Four-Year Unit of the University System of Georgia
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical