IMMUNIZATIONHEALTHHISTORY

Please complete this form below, attach a copy of supporting documentation if available
(i.e. immunization records, lab results etc.) .
NAME:

( M / F ) Date of Birth:

Grade:

HOME INSTITUTION: ________________________________ COUNTRY:_________________________

This is to certify that the above mentioned has the following immunization status.
DISEASE

IMMUNIZATION

Please complete the sections below.

REQUIREMENT
Measles

2 doses of vaccine OR
positive titer* to measles

If you have received vaccine, please list the date(s) of

vaccination:
Dose #1:

(*1:8(NT), 1:256(PA), or

Dose #2:

16.0(IgG EIA))

Mumps

2 doses of vaccine OR

If you have received vaccine, please list the date(s) of

positive titer* to mumps

vaccination:
Dose #1:

(*+(IgG EIA))

Rubella

Dose #2:

2 doses of vaccine OR

If you have received vaccine, please list the date(s) of

positive titer* to rubella

vaccination:

(* 1:32(HIor 8.0(IgG EIA))

Dose #1:

Varicella

2 doses of vaccine OR

If you have received vaccine, please list the date(s) of

(Chickenpox)

positive titer* to varicella

(*1:8(IAHA), +(IgG EIA), or + skin

Dose #2:

vaccination:
Dose #1:

Dose #2:

test)

TB

documentation of a normal

(Tuberculosis)

chest x-ray within the last 12

Date of x-ray:

Result:

months

Hepatitis B

3 consecutive doses of
vaccination

If you have received vaccine, please list the date(s) of

vaccination:
Dose #1:

Dose #2:

Dose #3:

Signature of physician:

Date: