FLORIDA STATE UNIVERSITY
Immunization Form
Part A– Print or type. Illegible form will not be processed
LAST NAME: __________________________________ FIRST NAME: __________________________________ DOB: _______________
EMPLID_____________________________________ EMAIL__________________________________________ PRIMARY PHONE#_____________________________
*Hepatitis B (Required or Complete Section 6)
3 doses of vaccine OR a blood test showing immunity
Dose 1 _____/_____/____
MM / DD / YR
Dose 2 _____/____/____
MM / DD / YR
Dose 3 ____/____/____
MM / DD / YR
Measles, Mumps, Rubella (Required)
2 doses of vaccine OR a blood test showing immunity
Dose 1 _____/_____/____
MM / DD / YR
Dose 2 _____/_____/____
MM / DD / YR
COVID-19 Vaccine (Optional) Please circle
type of vaccine (Pfizer/Moderna/Janssen)
Dose 2 ____/____/____
MM / DD / YR
*Waiver information: I have received the required information regarding the risk of acquiring Meningococcal Meningitis and Hepatitis B and the
benefits of receiving immunizations to reduce those risks. I also understand that I am required to receive these immunizations or to actively decline the
immunizations by checking the boxes and signing below. I understand that I may decline either or both immunizations and that declining these vac-
cines now does not mean I may not receive them in the future.
Patient Signature: ________________________________ Date: _________________
Meningitis Waiver Hepatitis B Waiver
Authorization and additional comments:
The immunizations dates and any statement of contraindications to immunizations entered on this document are, as of the date signed, verified by my
signature below. Additional comments:_____________________________________________________________________________________
__________________________________
Clinician OR Records Custodian Name
__________________________________ ____________
Clinician OR Records Custodian Signature DATE OFFICE STAMP
Please list any relevant personal and family medical history: ________________________________________________________________________
Do you have any allergies (including Medications): No Yes Please list if yes:_________________________________________________
REQUIRED AUTHORIZATIONS FOR CARE FOR STUDENTS UNDER THE AGE OF 18: I authorize health center personnel to provide medical and
surgical care including examinations, treatment, immunizations and the like for my son/daughter. In the event of serious disease or injury, I understand that all reasonable
efforts will be made to contact me but failure to contact will not prevent emergency treatment if necessary to preserve life or health.
Signature: _______________________________________________________________ Date: _____________________
*Meningococcal Meningitis Serogroups (Required or
Complete Section 6)
1 dose since age 16. (such as Menactra, Mencevax,
Menomune, MCV4, Menveo, and ACYW-135)
Dose 1 ____/____/____
MM / DD / YR
Dose 2____/____/____
MM / DD / YR
Meningitis B (Optional) Please cir cle type of vaccine (Bexsero or Tr umenba)
Meningitis B ____/____/____
Dose 1 MM / DD / YR
Meningitis B ____/____/____
Dose 2 MM / DD / YR
Meningitis B ____/____/____
Dose 3 MM / DD / YR
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This section to be completed by your healthcare provider
Once Completed: You may submit this form to the Health Compliance Office in one of the following ways:
Email: healthcompliance@fsu.edu Please be aware that email sent over the Inter net is not consider ed secur e. FSU shall not liable for any br each of
confidentially resulting from this form of communication.
Fax: 850-644-8958
Mail: 960 Lear ning Way, Tallahassee, FL 32306-4178
FSU Dropbox: https://dropbox.fsu.edu
In person: You may also dr op off your forms in person to the Health Compliance office at UHS dur ing r egular business hour s http://uhs.fsu.edu/about/
contact-us at 960 Learning Way.
Tetanus-Diphtheria and Pertussis (Tdap) (Optional) (Required for NCAA Athletes)
Incoming students should have one Tdap booster at 11 years of age or older.
Tdap ____/____/____
MM / DD / YR
10.
Rev 2/18
Meningitis B ____/____/____
Dose 2 MM / DD / YR
Dose 1 ___/____/___
__
MM / DD / YR