2022 Immunization Form

Instructions

Please complete all sections of this form. The confidential information on this form is strictly for the Office of Student Life and will not be released to anyone without written consent except to authorized personnel in the event of an emergency.

Personal Information

First Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Recommended Immunizations

The Indiana State Health Department recommends that students entering college for the first time have the following immunizations.

Hepatitis A
Requires 2 vaccinations

#1 Date:

# Date:

Hepatitis B
Requires 3 vaccinations

#1 Date:

#2 Date:

#3 Date:

MMR
All entering college students born after 1956 should have two dates of live measles vaccine.
Requires 2 vaccinations

#1 Date:

#2 Date:

Polio
Requires 3 vaccinations

#1 Date:

#2 Date:

#3 Date:

Tetanus-Diptheria or Tdap
TD in the last 10 years.

Date:

Tdap Date:

Varicelle (Chickenpox)

Yes, I had chickenpox. Date:

No, I have not had the Varicella (Chickenpox) disease.
If you have not had the Varicella disease you will need 2 vaccinations.

#1 Date:

# 2 Date:

Tuberculin PPD (within the last 6 months)
A tuberculin skin test is strongly encouraged within six months before initial entrance into college. Please give date of results below. (If skin test is positive a chest x-ray is recommended.)

Mantoux Skin Test (PPD Test) If you have a positive PPD test, a chest x-ray is required. Attach a copy of the x-ray report to the health form.

Date Read:

Read by:

Result:

COVID 19 Vaccination

#1 Date:

#2 Date:

Booster Date:

Meningitis Information

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitides, also knows as meningoccus. These illnesses are often severe and include infections of the lining of the brain and spinal cord (meningitis) and bloodstream infections (bacteremia or septicemia).

Menningococcus bacteria are spread through the exchange of respiratory and throat secretions like spit (e.g. by living in close quarters, kissing). Meningococcal disease can be treated with antibiotics, but quick medical attention is extremely important. Keeping up to date with recommended vaccines is the best defense against meningococcal disease.

If you have further questions about Meningitis, you may refer to this site by clicking here.

It is required by Indiana law that incoming college students receive information regarding Meningitis. This information is provided to you in the above paragraphs.

In order to meet the requirements of the state of Indiana, we must have your signature on file as proof of having received this information.

Our records indicate that we do not have your signature on file, nor have you received the vaccine. By signing this you acknowledge receipt of this information, and that you have read and understood it accordingly.

In place of your signature, please type your full legal name.