Proof Of Immunization Compliance
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1
2Proof of Immunization Compliance
Required by Texas State Department of Health
Services/Clinical Facilities
Applicant Name:____________________________________________
DOB:___________________ Last 4 of SS#_____________
To be completed by a Physician or Other Health Care Provider. Please do not sign the compliance form unless the named
person has proper vaccines or immune test.
Measles (Rubeola)*:
A. Two doses of measles-containing vaccine
on or after January 1, 1968 and at least Date#1_________________________Date#2_____________________________
30 days apart OR
(mm/dd/yy)
(mm/dd/yy)
B. Serologic test positive for measles antibody** Date____________________________ Results____________________________
(mm/dd/yy)
Mumps*:
A. One dose of mumps vaccine on or after
January 1, 1957 OR
Date#1___________________________Date#2____________________________
(mm/dd/yy)
(mm/dd/yy)
B. Serologic test positive for mumps antibody** Date_____________________________ Results____________________________
(mm/dd/yy)
Rubella*:
A. One dose of rubella vaccine on or after
the first birthday OR
Date_______________________________________________________________
(mm/dd/yy)
B. Serologic test positive for rubella antibody** Date_____________________________ Results____________________________
(mm/dd/yy)
*Combined MMR Vaccine is vaccine of choice if recipients are likely to be susceptible
**Must include date of test collection
Hepatitis B: (3 doses) IMPORTANT NOTICE TO APPLICANTS: Please be aware that all of our students are
required to have completed the HEP B series before the start of school. If you have not yet begun to receive
this series, or if you will not have it completed before classes begin, you will not be eligible for
admission. THIS IS A NON-NEGOTIABLE REQUIREMENT.
A. The minimum interval between the first two
doses is 4 weeks, and the minimum
Date #1___________________________________________________
interval between the second and third
(mm/dd/yy)
doses is 8 weeks. However, the first and
Date #2___________________________________________________
third doses should be separated by no less
(mm/dd/yy)
than 16 weeks. It is not necessary to restart
Date #3___________________________________________________
the series or add doses because of an
(mm/dd/yy)
extended interval between doses
AND- MUST HAVE SEROLOGY
Serologic test positive for Hepatitis B antibody
Date________________________ Results__________________________
Must include date of test collection and results
(mm/dd/yy)
Note: An accelerated dosing schedule with Twinrix vaccine (Hepatitis A and Hepatitis B recombinant) may be an option to
meet Texas DSHS requirements for Hepatitis B immunization.
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