Certificate Of Immunization Page 2
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2(Revision – Jan. 2007
PG 2 of 2)
UNIVERSITY SYSTEM OF GEORGIA
RECOMMENDED
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: _____/_____/__________
RECOMMENDED IMMUNIZATION INFORMATION
(See the Immunization Requirements & Recommendations for USG Students documentation)
DATE OF POSITIVE
DATE
DATE
DATE
VACCINE
LAB/SEROLOGIC
HISTORY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
EVIDENCE
Human
/
/
/
/
/
/
Papillomavirus
4
Hepatitis A
Type Series:
5
/
/
/
/
/
/
/
/
2 Dose Series
3 Dose Series
Meningococcal
5
/
/
/
/
Influenza
5
/
/
/
/
/
/
4 – Strongly recommended for all unvaccinated women through age 26 years.
5 - Strongly recommended but not required.
CERTIFICATION OF HEALTH CARE PROVIDER
(This information is required)
Name: _____________________________ Signature: _______________________________________________
Address: _______________________________________________________________________________________
Date of Issue: ______/______/__________ Telephone: ______________________________________________
Student Signature: _____________________________________ Date: _____/_____/_______________
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