DISTRICT OF COLUMBIA VACCINATION FORM
District of Columbia law requires that all students attending four-year colleges and universities provide evidence of having received the following
vaccinations: measles, mumps and rubella; tetanus, diphtheria and acellular pertussis; Hepatitis B; and Varicella (chickenpox).
If you received regular childhood immunizations, you may have received all of these vaccinations already. You may obtain copies of your
immunization records from the doctor or agency that administered the immunizations or, possibly fr om the elementary or secondary school you
attended. If you do not have any record of your vaccinations, your current doctor may test you for immunity to these diseases.
You do not need to comply with this requirement if any of the following apply to you: you are 26 years old or older; you have a medical condition
that prevents you from receiving vaccinations; or you have a religious objection to vaccinations.
PLEASE COMPLETE THIS FORM AND RETURN IT TO THE ADMISSIONS OFFICE PRIOR TO ENROLLMENT.
Student ID Number Date of Birth Student Name
RECORD OF IMMUNIZATION
Unless
you meet one of the exemption categories listed below, please have your doctor complete the following information OR
provide copies of an official school immunization record or public health department immunization record.
Td/Tdap
Tetanus/Diptheria (Td) or
Tetanus/Diptheria/Acellular
Pertussis Vaccination
Date of Date of Date of Booster Dose
OR Student has laboratory
Date of First Second Dose Third Dose
(At least 10 years after
evidence of immunity to this
Dose
(At least 4 weeks (At least 6 months
the primary series
if disease (please initial)
after first dose) after second dose)
vaccinated in childhood)
Mumps Vaccination
Rubellla Vaccination
MMR
Measles Vaccination
Date of First Dose
(At least 28 days after first dose) to this disease (please initial)
Date of Second Dose OR Student has laboratory evidence of immunity
Date of First
Dose
Date of
Second Dose
(Between 4-8 weeks after
first dose)
Date of
Third Dose
(At least 8-16 after second dose but not
earlier than 16 weeks after first dose)
OR Student has laboratory
evidence of immunity to this
disease (please initial)
Hepatitis B
Hepatitis B Vaccination
Date of First Dose
Date of Second Dose
(At least 28 days after first dose)
OR Student has laboratory or other evidence of
immunity to this disease (please initial/describe)
Varicella
Varicella (Chickenpox)
Signature of Doctor Completing this Form Printed Name of Doctor Phone Date
Student Signature Date
MEDICAL EXEMPTION - If immunization is medically contraindicated for this student, please indicate the reason(s) why on the
back of this form or on an attached page and indicate the specific period of time that the student should not be immunized.
RELIGIOUS E
XEMPTION (to be completed by the student) - If you object to vaccination requirements on religious grounds,
please write a statement on the reverse side of this form or on an attached page indicating why receiving vaccinations conflicts with
your religious beliefs.
CERTIFICATION (all students to sign)
I certify that the above information is true and correct to the best
of my knowledge. I understand that if I have not
received
immunizations due to medical or religious
grounds, I may be temporarily excluded from classes and from participating in Strayer
University-sponsored activities during a vaccine-preventable disease outbreak or
threatened outbreak.
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