Mandatory Immunization Screening 1
The University of Central Missouri requires all students and employees born on or after January 1, 1957 to present documentation of
immunity to MMR. (Please attach immunization documentation or copy of lab result.)
2 doses of MMR vaccine. Dose 1 given at age 12 months OR Titer (blood test) results proving immunity to MMR
or later. Dose 2 given at least 28 days after dose 1.
Check the following statement(s) that applies:
____ I am from, were born in, or have visited for more than 2 months Asia, Africa, Central or South America, Caribbean, Eastern Europe, or
Oceania/Pacific Islands. (For a complete list of countries, see page 2.)
____ I have been diagnosed with a chronic medical condition that may impair my immune status.
____ I am or have been a health care worker.
____ I have been a volunteer or an employee of a nursing home, prison, homeless shelter, AIDS facility, or other residential institution.
____ I have close contact with someone who has or had active TB.
If
any of the statements above do apply, you must provide documentation of one of the following:
• Negative TB skin test done in the United States in the last year (attach copy),
• Negative QuantiFeron Gold/ T-spot TB test in the last year (attach copy),
• Chest X-Ray negative for active TB done in the United States in the last year (attach copy),
• Records of treatment regimen taken for TB provided (attach copy).
____ None of these statements apply to me. (No further documentation needed.)
Check the following statement that applies:
____ I have received the meningococcal vaccine after my 16
th
birthday (Menactra or Menveo). (Attach immunization documentation.)
____ I have not received the meningococcal vaccine. I have received and read the Meningococcal Disease Fact Sheet
, written by the Center
for Disease Control and Prevention explaining the potential benefits of vaccination. (Attach medical/religious waiver.)
Signature: __________________________________________________________ Date: __________________________
□ meets MMR requirements
□ meets TB requirements
□ meets Meningitis requirements
□ Entered ____________
SIGNATURE
New Student Current Student Transfer Student Graduate Student Employee
Name: __________________________________________________________________________ Date of Birth: _________________________
LAST FIRST MI MM/DD/YYYY
700 #: _______________________________________________ Home/Cell Phone: (_________) __________________________________
Part I 2 Measles, Mumps, Rubella (MMR) Vaccinations Required for all students/employees
Part II Tuberculosis (TB) Screening Required for all students/employees
Part III Meningococcal Vaccine Required for Students living in University Housing
UCM Health Center
600 S. College, UHC 229
PHONE: 660-543-4770
FAX: 660-543-8222
EMAIL: uhc@ucmo.edu
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