Dpt Immunization Form - Ung

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University of North Georgia
Certificate of Immunization for
Doctorate of Physical Therapy Applicants
Make a copy of this completed form for your records and send the form to the address below after April 1, 2016, but before May 8, 2016.
This form must be fully completed. Dates are required for all applicable immunizations.
STUDENT INFORMATION:
Name (Last) ________________________________ (First) _____________________________ (MI) ________________
Date of Birth ____
____
______
Term of Application ____________________________________________________
/
/
IMMUNIZATION INFORMATION (DATES ARE REQUIRED)
DATE OF POSITIVE
DATE
DATE
DATE
LAB/SEROLOGIC
VACCINE
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
EVIDENCE
MMR
1
or
/
/
/
/
Measles
/
/
/
/
/
/
Mumps
/
/
/
/
/
/
Rubella
/
/
/
/
/
/
(or history of)
Varicella
2
(chicken pox)
/
/
/
/
/
/
Most recent date
Tetanus-Diptheria (DTP,
DTaP, Tdap, or Td)
/
/
Within 10 years
Type Series:
Hepatitis B
/
/
/
/
/
/
___ 2 Dose Series
/
/
___ 3 Dose Series
PPD (Mantoux Skin Test
3
Required!)
/
/
Strongly Recommended
4
Meningococcal Vaccine
/
/
1.
Not required if born before 1957.
2.
Not required if born in the US before 1980.
3.
PPD must be administered no more than 3 months prior to start of class. Repeat testing required annually. If you have a
positive PPD, a chest x-ray and completion of the Positive PPD Questionnaire are required.
4.
Meningococcal (strongly recommended) – l dose meningococcal conjugate vaccine (preferred) or 1 dose of meningococcal
polysaccharide within 5 years prior to matriculation or signed document that student has received and reviewed
information about the disease as required by O.C.G.A. §31-12-3.2.
PERMANENT OR TEMPORARY IMMUNIZATION EXEMPTION
This student is exempt from the above immunizations on the ground of permanent medical contraindication.
 T his student is temporarily exempt from the above immunization until ________/____/________.
CERTIFICATION OF HEALTH CARE PROVIDER (REQUIRED)
______________________________________
Name of health care provider
______________________________________
________________________________________
_____________
Address of health care provider
Signature of physician or health care provider
Date
Mail, Fax, or eMail:
University of North Georgia
Fax: (706) 867-2795
Graduate Studies
Email:
grads@ung.edu
82 College Circle
Dahlonega, GA 30597
If you need this document in another format, please email
LYoungblood@ung.edu
or call (706) 864-1863

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