Stanford University Immunization Form For Medical Students
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1Stanford University Immunization Form for Medical Students
FAX to 650-498-1118
Last Name: ____________________________ First Name: ________________Middle Initial: _____
Date of Birth: ____/____/____
SU ID Number (if known): ______________________
DO NOT SEND I M M UN I ZATI ON RECORDS; USE THI S FOR M ONLY
REQUI R ED I M M UNI ZATI ONS
MMR
Date #1: (Given on or after 12 months of age)
Date #2: (Given 28 days or more after #1 dose)
2 doses required or individual
vaccines as listed below
Measles (Rubeola)
Date #1:
Date #2:
OR Laboratory Evidence of Immunity
Include R eport
2 doses required for all students
born after 1956
(R evaccinate for Equivocal Titer)
Mumps
Date #1:
Date #2:
OR Laboratory Evidence of Immunity
Include R eport
2 doses required for all students
(R evaccinate for Equivocal Titer)
regardless of age
Rubella (German Measles)
Date #1:
OR Laboratory Evidence of Immunity
Include R eport
1 dose required for all students
(R evaccinate for Equivocal Titer)
regardless of age
Hepatitis B
Date #1:
Date #2:
Date #3:
OR Laboratory Evidence of Immunity
Include R eport
3 doses required
(R evaccinate for Equivocal Titer)
Or, if History of Hepatitis B Disease:
Must include report for Hepatitis Core Antibody, Hepatitis Surface Antibody & Hepatitis Surface Antigen titers
Tetanus-Diphtheria-Pertussis
Booster must be
Tdap Date:
Vaccine must be Tdap regardless
within the past 10
of last Td vaccine
years
Varicella (Chicken Pox)
Date # 1:
Date #2:
OR Laboratory Evidence of Immunity
Include R eport
2 doses required
(R evaccinate for Equivocal Titer)
HI GHLY R ECOM M ENDED I M M UN I ZATI ONS
Meningococcal Vaccine
List Type of Vaccine:
Date:
HPV (List Type and Date)
Date #1:
Date #2:
Date #3:
Hepatitis A
Date #1:
Date #2:
Pneumococcal Vaccine
(*) History of asthma, other lung diseases, immune issue,
Date:
smoker. List type of Vaccine:
if indicated (*)
ADDI TI ONAL I M M UN I ZATI ON
HI STORY
Japanese Encephalitis
Date #1:
Date #2:
Date #3:
Rabies
Date #1:
Date #2:
Date #3:
Date #4:
□
□
Date:
Typhoid
Injectable
Oral
Yellow Fever
Date:
Primary Polio Series
Date #1:
Date #2:
Date #3:
Date #4:
Adult Polio Booster
Date:
Primary Tetanus (DTaP) Series
Date #1:
Date #2:
Date #3
Date #4
Date #5
Signature of Health Provider: _______________________________________
Date: ______________
***Signing Provider is verifying all dates above are accurate
Physician / Medical Provider Name: (Please Print) / Clinic Stamp: ________________________________
Address:______________________________________________________________________________
Phone number: ___________________________Fax Number: __________________________________
5
.2014
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Parent category: Medical