College and Post-Secondary Immunization Record

Last Name
First Name
M.I
Suffix
Address
City
State
Zip
Date of Birth
Student ID#
Date of Enrollment - Month/Year
VACCINES: Tdap or Td - Requirements: 1 Tdap/Td booster within the last ten years. Please provide the dates below
Vaccines:
Tdap Td
Date of Vaccine: (m/d/y)
VACCINE: MMR Requirements: 2 doses or positive titers. Minimum of 4 weeks between doses, ist dose given after first birthday
Date of MMR Vaccine #1: (m/d/y)
Date of MMR Vaccine #2: (m/d/y)
OR
Measles Vaccine Date: (m/d/y)
Mumps Vaccine Date: (m/d/y)
Rubella Vaccine Date: (m/d/y)
VACCINE: Meningococcal - Requirements: One dose for first year students living in campus based housing
1st year in campus based housing? (required)
Yes No
Meningococcal Vacinne Date: (m/d/y)
VACCINE: Varicella, Requirements: 2 doeses of varicella vaccine or history of disease or positive titer. Minimum of 4 weeks between doses if age 13 or older (12 weeks for under 13)
History of disease?
Yes No
Date of Varicella Vaccine #1: (m/d/y)
Date of Varicella Vaccine #2: (m/d/y)
OR positive titer Date: (m/d/y)
VACCINE: Hepatitis B, Requirements: 3 doeses or positive titer. Minimum of 4 weeks between doses 1 & 2. Minimum of 8 weeks between doses 2 & 3. (3rd dose must be 16 weeks from first dose)
Date of Hepatitis Vaccine #1: (m/d/y)
Date of Hepatitis Vaccine #2: (m/d/y)
Date of Hepatitis Vaccine #3: (m/d/y)
OR
Positive titer Date: (m/d/y)
Health Care Provider Information
Name of Health Care Provider:
Address:
City:
State:
Zip
Form Filled Out By:
Your Phone Number:
Questions: Please call CSJ at (802) 776 - 5212

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College of St. Joseph

College and Post-Secondary Immunization Record