New Student Immunization Record

Student Info

Email Address

First Name

Last Name

Birthdate

USM Student ID

Residential Student

Yes

No

Student Athlete

Yes

No

Major

Required

A. M.M.R (Measles, Mumps, Rubella) (two doses required

MMR Month/Year Received Dose 1:

MMR Month Year/Year Received Dose 2

B. Meningococcal Meningitis (Dose or booster required after the age of 16)

Meningitis Month/Year Received:

Recommended

C. Tuberculosis Screening

D. HIB (four doses)
HIB Dose 1 (Month/Year Received)

HIB Dose 2 (Month/Year Received)

HIB Dose 3 (Month/Year Received)

HIB Dose 4 (Month/Year Received)

E. Polio

Completed primary series of Polio immunization:

Yes

No

Date of Last Polio Booster (Month/Year):

F. Tetanus-Diphtheria * Tetanus-Diphtheria booster must be within the last ten years

Tetnus-Diptheria Booster Date (Month/Year)

G. Hepatitis B

Hep B Dose 1 Month/Year

Hep B Dose 2 Month/Year

Hep B Dose 3 Month/Year

H. Varicella (Chicken Pox)

Hx of disease:

H. Varicella (Chicken Pox)

Hx of disease:

Yes

No

Vaccinated Dose 1
Month/Year

Vaccinated Dose 2
Month/Year

Health Care Provider Information

Name of Health Care Provider

Phone Number of Health Care Provider

Address of Health Care Provider

Signature

By typing my name below and clicking the submit button, I agree and understand that the electronic submission of this form constitutes my official signature as stipulated by the University of Saint Mary and the state of Kansas.

Student Signature:

Today's Date