Immunization Requirement Form printable pdf download

Immunization Requirement Form

ALL MATRICULATED STUDENTS ENROLLED FOR SIX (6) OR MORE CREDITS MUST COMPLETE THIS FORM. Students will not be allowed to

register or attend classes unless they submit this completed form. If any portion of this document is illegible, it will not be processed. Please

submit copies of all supporting documentation and keep originals for your records. Supporting documentation does not preclude the comple-

tion of this form. Please print legibly.

Part One: Student Information

First semester at Pace University

FALL

SPRING

SUMMER

YEAR ___ ___ ___ ___

■

Student ID #: U ____ ____ ____ ____ ____ ____ ____ ____ Campus:

NYC

PLV

WP – Grad Center

WP – Law School

■

_____ _____

_____ _____ _____ _____

LAST NAME

FIRST NAME

MIDDLE INITIAL

DATE OF BIRTH

__________________________________________________________ ( ____ ____ ____) _____ _____ _____ - _____ _____ _____ _____

PACE E-MAIL ADDRESS

PHONE NUMBER

Part Two: Meningococcal Meningitis

Completion of this part is not optional. You must check ONE of the boxes and sign below to be in compliance with NYS Public Health

Law 2167. For students under the age of 18, signature of parent or guardian is also required.

I have:

Had the meningococcal meningitis immunization within the past 10 years. Date of shot _____ /_____ / _____

■

Read or have had explained to me the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vacci-

■

nation. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease.

STUDENT’S SIGNATURE

DATE

PARENT’S or GUARDIAN'S SIGNATURE

DATE

Part Three: Measles, Mumps, Rubella

NOTE: Please see the reverse side of this form for information on completion of this part and acceptable supporting documentation.

MMR VACCINATION:

HISTORY OF DISEASE:

This must be verified below by a health care provider.

MMR Dose #1

*Please note that the first

_____ _____

MMR/Measles Dose must be

on or after your first birthday.

Measles

MMR Dose #2

_____ _____

Dose #1

Dose #2

Mumps

_____ _____

Measles

Rubella

XXXXXXXXXXXXXXXXX

_____ _____

Mumps

XXXXXXXXXXXXXXXXX

EXEMPTIONS:

_____ _____

Rubella

XXXXXXXXXXXXXXXXX

Religious Exemption: If a student has a deeply held aversion to receiving

_____ _____

■

vaccinations for religious reasons, a letter signed by the student stating

ANTIBODY TITERS:

this is required.

Measles

Result

Medical Exemption:

Temporary

Permanent

_____ _____

____________________

■

Requires a letter from a health care provider detailing conditions.

Mumps

Result

_____ _____

___________________

Birth Exemption: Proof of birth prior to January 1, 1957 must be submitted

■

Rubella

Result

with this form.

_____ _____

___________________

Health Care Provider Information:

Name (print):

____________________________________________________________________________

Signature:

OFFICIAL STAMP AND/OR LICENSE NUMBER OF HEALTH CARE

________________________________________________________________________________

PROVIDER IS REqUIRED.

Phone Number: (

)

____________

_________________________________________________________________

FOR OFFICE OF STUDENT A SSISTANCE - IMMUNIZATION COMPLIANCE USE ONLY

Received: ________________________

Entered: ______________ OSA rep: ______________

Missing Info

Immunization Requirement Form

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