Certificate Of Immunization
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1
2(Revision – Jan. 2007 PG 1 of 2)
UNIVERSITY SYSTEM OF GEORGIA
REQUIRED
CERTIFICATE OF IMMUNIZATION
(
Return this to the institution)
Return documentation to the college or university that you are applying to. Retain a copy of the completed form for your records.
STUDENT INFORMATION
Social Security Number/Student ID: _________________ - __________________ - ______________________
Name: (Last)_____________________________(First)__________________________(Middle)____________________
Address: _________________________________________________________________________________________
City: _______________________________ State: ______________ Country: ________________ Zip Code: _________
Term/Year of Application: _____________ Age at time of application: _____ Date of Birth: _____/_____/__________
REQUIRED IMMUNIZATION INFORMATION
(See the Immunization Requirements & Recommendations for USG Students documentation)
DATE OF POSITIVE
DATE
DATE
DATE
HISTORY
LAB/SEROLOGIC
VACCINE
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
EVIDENCE
MMR
1
/
/
/
/
Measles
1
/
/
/
/
/
/
Mumps
1
/
/
/
/
/
/
Rubella
1
/
/
/
/
/
/
Varicella
(History of Varicella)
3
/
/
/
/
/
/
/
/
Tetanus-Diphtheria
(Most recent date)
/
/
(DTP, DTaP, Tdap, or
Td within 10 years)
Hepatitis B
Type Series:
2
/
/
/
/
/
/
/
/
2 Dose Series
3 Dose Series
1—Not required if born before 1957.
2—Only required of students who are 18 years of age or younger at time of expected matriculation.
3—Required for all US born students born in 1980 or later; all foreign born students regardless of year born.
PERMANENT OR TEMPORARY IMMUNIZATION EXEMPTION
This student is exempt from the above immunizations on the ground of permanent medical contraindication.
This student is temporarily exempt from the above immunization until ______/______/____________.
CERTIFICATION OF HEALTH CARE PROVIDER (This information is required)
Name: _____________________________ Signature: _______________________________________________
Address: _______________________________________________________________________________________
Date of Issue: ______/______/__________ Telephone: ______________________________________________
EXEMPTIONS
Check the appropriate box, sign, and date if you are claiming exemption of the immunization requirement for one of the following reasons:
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: _____/_____/_______________
I declare that I will be enrolling in ONLY courses offered by distance learning. I understand that if I register for a course that is offered
on-campus or at a campus managed facility this exemption becomes void and I will be excluded from class until I provide proof of immunization.
Student Signature: _____________________________________ Date: _____/_____/_______________
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