Return this completed form to:
UNT Health Science Center Office
of the Registrar, SSC 244
3500 Camp Bowie Blvd.
Fort Worth, TX 76107-2644
FAX: (817) 735-0448 OR Email: Health@unthsc.edu
Bacterial Meningitis Immunization Record
Notice: THIS FORM IS DUE TEN (10) DAYS PRIOR TO THE FIRST DAY OF CLASS
Purpose of this form: This form may be used by any student under the age of 22 entering the UNT Health Science Center in order to satisfy the
requirement to submit evidence of a bacterial meningitis vaccination, in compliance with Texas Senate Bill 1107.
STUDENT INFORMATION
UNTHSC Student ID #
Enrollment Term (Check One)
Year
Fall Summer: 3 Week/5 Week 1/10 Week
Spring Summer: 5 Week 2
Last Name
First Name
Middle Initial
Mailing Address
Apart
ment #
Daytime Phone #
City
State
Zip Code
Date of Birth
Age Email
Addre
ss
SELECT OPTION 1 OR 2
Option 1: Select type of attachment
(Documentation must be in English or accompanied by a notarized translation)
Official copy of immunization record stating the type of vaccine administered and signed by a Health Care Provider
Medical Exemption affidavit or certificate
Texas Department of State Health Service Exemption for Reasons of Conscience form
Official immunization records generated by a state or local health authority
Official immunization record received from school official, including a record from another state
Option 2:
To be completed by a Health Care Provider -
USE BLACK INK
Date of Immunization
Month Day Year
Official Stamp: Health Care Provider's Name, Address, and Phone Number
Signature and Title of Health Care Provider
Date
Month
Day
Year
I have read and understand the Bacterial Meningitis immunization requirements. I certify that, to the best of my knowledge, the
above information (including attached copies) is true and correct.
Student's Signature -
USE BLACK INK ONLY
Month Day Year
Office Use Only
Date Received
Date Completed
Accepted
Denied
Incomplete
Completed By
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