Fillable Immunization Record Form (George Mason University)

Fill Online, Printable, Fillable, Blank Immunization Record Form (George Mason University) Form

Use Fill to complete blank online GEORGE MASON UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Immunization Record Form (George Mason University)

On average this form takes 16 minutes to complete

The Immunization Record Form (George Mason University) form is 6 pages long and contains:

  • 0 signatures
  • 41 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

U.S.A. forms for George Mason University

BROWSE GEORGE MASON UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Immunization Record Form
shs.gmu.edu/immunizations
INSTRUCTIONS
Visit the website for office hours and more information.
• Completed immunization forms are due by August 1st for Fall/Summer and January 4th for Spring enrollment.
• All records must be in English. Student and Healthcare Provider must fill out the Immunization Form in ink
("see attached" is not acceptable documentation). All dates must be entered onto form (check marks not acceptable).
• Student name and G# must be on each page of submitted form and records.
• ALL students must complete Parts 1 and 3. Part 2 must be completed by parent/guardian if student is under 18 years of age.
• ALL students born after 12/31/1956 must provide proof of immunizations listed in Part 5.
• Part 4 (if required), Part 5, Part 6 and Part 7 of this form must be completed and signed by a healthcare provider. Part 4 refers to
whether a TB test is required based on answers from Part 3.
• Records that are late or incomplete after appropriate deadlines will be assessed a late fee and a hold will be placed on the
student's Patriot Web account. The hold will prevent class registration for the following semester.
• Transcription service is available for a fee at Student Health Services. If a student is unable to provide appropriate documentation,
immunizations and/or titers are also available for a fee.
• Students will receive communication from the Immunization Office regarding compliance/non-compliance through a secure
message to their Mason email. The notification will state that they have a secure message and should log into the patient portal to
read it. These messages may go to a spam/junk email; check or edit mail options.
• Student Health Services reserves the right to request supporting documentation of your immunization records, and
request titers and/or vaccinations at your expense.
SUBMIT FORM AND RECORDS (DO NOT FAX OR EMAIL)
Upload to Patient Portal (preferred method): https://gmu.medicatconnect.com
Mail records: George Mason University Student Health Services 4400 University Drive, MS 2D3, Fairfax, VA 22030
Students can check record status in the portal.
Print services (on campus) offers scanning service for students.
PART 1. PERSONAL INFORMATION - TO BE COMPLETED BY ALL STUDENTS, PRINT LEGIBLY
Legal
Last Name
First Name
Student G#
U.S. Address
City
Zip Code
Date of Birth
Cell Phone
State
Home Phone
Legal
Parental permission or the consent of a legal guardian must be obtained to provide medical or surgical care to minors. To avoid
delays in treatment in the event of illness or accident, please obtain the signature of a parent/legal guardian if you are under 18
years of age at the time of enrollment.
I hereby authorize the staff of George Mason University Student Health Services to assess, test, administer vaccines, and if
necessary, treat my minor or dependent as deemed advisable.
Parent/Guardian Signature:
Date:
Printed Name of Parent/Guardian: Relationship:
ALLOWABLE EXEMPTIONS: DO NOT APPLY TO TUBERCULOSIS SCREENING/TESTING
Medical: Mason Medical Exemption Form completed and signed by Religious Exemption: Original, notarized Commonwealth of Virginia
healthcare provider. Upload to the patient portal. form CRE-1 required.
PART 2. MINOR CONSENT - ONLY IF STUDENT IS UNDER 18 YEARS AT TIME OF ENROLLMENT
11/12
Page 1 of 6
Select state
Student Name: G #
Birth:
Date of
Select Yes or No
PART 3 . TUBERCULOSIS SCREENING -
Baseline Individual TB Risk Assessment
Students are considered at increased risk for TB and should be
tested if
any of the following statements are marked "Yes"
Have you ever tested positive for TB?
If yes go to Part 4. You will need to supply documentation of a positive test (historical or
current), and documentation of a chest x-ray dated within 3 months of classes starting.
If no, go to next question.
Yes
No
Have you ever lived in any country other than the United States, Canada, Australia,
New Zealand, Northern Europe or Western Europe for more than 1 month at a time?
Yes
No
Have you ever traveled to any country other than the United States, Canada, Australia,
New Zealand, Northern Europe or Western Europe for more than 1 month at a time?
Yes
No
Do you have an immuno-suppresive disease?
Persons who are receiving immune-suppressive medications such as corticosteroid or
drug therapy following organ transplantation and persons with immune-suppressive
conditions such as HIV, diabetes mellitus, chronic renal failure, leukemia, or cancer.
Yes
No
Have you ever received a Bacillus Calmette-Guerin (BCG) vaccine?
No
Yes
Have you had close contact with anyone who is or was sick with tuberculosis (TB)?
Yes
No
Have you resided in, volunteered or worked in a prison, nursing home, hospital, or homeless
shelter?
11/12
Page 2 of 6
Yes
No
Yes
Do you have any symptoms of active tuberculosis, such as: Cough > 3 weeks, night
sweats, fever unexplained weight loss and/or fatigue?
No
Pages 3 and 4 to be completed by your Healthcare Provider
PART 4. TUBERCULOSIS TEST - If the student answered YES to any of the
screening questions on Page 2 they are required to have a Tuberculosis Test. If the student
answered NO to all the screening questions please proceed to Page 4: Required
Immunizations. TO BE COMPLETED AND SIGNED BY A HEALTHCARE PROVIDER. All lab
reports and chest x-rays must be submitted with this form.
Students MUST undergo Tuberculin skin test (TST) OR have one Interferon Gamma Release
Assay Test (IGRA) if THEY answered yes to 1 or more risk questions. All testing and x-rays must be
dated less than 3 months from the first day of classes.
Has patient ever had a positive tuberculin skin test or blood test?
Yes
No
If No: complete Section A
Result: ____________mm complete Section B & C
If yes: Date:__________
Students who have had BCG are required to have a TB test. It is recommended they do a TB
Immunoassay Blood Test (IGRA)
Section B: Chest X-Ray - If patient has a documented history of a positive TB test,
a chest x-ray report must be submitted with this form. Chest X-Ray must be dated
less than 3 months from the first day of classes
Section C: Treatment for TB or LTBI - Documentation of treatment must
be submitted with form
Date treatment started: _________________________
Date treatment completed: ____________________________
Name of medication:________________________________________________________________________________
Name of Practice:___________________________________________________________
Contact Phone Number: ________________________________
Healthcare Provider Signature: _________________________________________________ Date:________________
Must be 48-72 hours from
placement
Date of
Birth:
Date of
Birth:
Student Name:Student Name:Student Name: G #G #G #
Date of
Birth:
11/12
Page 3 of 6
Section A: TB Test - (Skin test OR Blood test) Copy of test/report must
accompany the form (test must be dated less than 3 months from the first day of classes)
Blood Test: IGRA - submit lab report
OR
Skin Test: Date Placed:_______________
Results: ___________mm Date Read: ______________
Please record actual mm of induration, transverse diameter; if no induration, write "0"
PART . REQUIRED IMMUNIZATIONS - TO BE COMPLETED BY A HEALTHCARE PROVIDER WHO MUST ALSO
OMPLETE AND SIGN PART 7
. SHS will not accept “see attached” all dates must be written in. All titer reports must be
ubmitted with the Immunization Record form for proper documentation.
TETANUS-DIPHTHERIA
5
C
s
Tdap within past 10 years
{
}
Tdap after age 11
AND after age 11
OR
AND TD within past 10 years
MEASLES, MUMPS, RUBELLA (MMR)
(1) (2)
2 doses of MMR required at least 1 month apart. First dose must be given on or after one year of age;
and after 1971 for combined MMR vaccine or after 1967 for individual doses
OR
Copy of titer lab work
indicating positive immunity
must be submitted with form
OR
TWO (2) DOSES OF EACH OF THE FOLLOWING VACCINES:
(1) (2)
Measles (Rubeola)
Mumps
(1) (2)
Rubella (German Measles)
(1) (2)
HEPATITIS B (HBV)
Must receive all three doses at appropriately spaced intervals to be considered immune
Copy of titer lab work
indicating positive
immunity must be
submitted with form
(1) (2) (3)
signed waiver on
OR OR
Hepatitis B
Hepatitis B Hepatitis B
Check One
Twinrix
Twinrix
Twinrix
part 8 of this form
MENINGOCCOCAL QUADRIVALENT (A, C, Y, W-135)
Administered between the ages of 16 and 21
(most recent date)
Preferred, administered simultaneously with Tdap if possible.
OR
signed waiver on part 8 of this form
OR
over 21 years of age
(not required to show proof of vaccination)
PART 6. RECOMMENDED IMMUNIZATIONS
- TO BE COMPLETED BY A HEALTHCARE PROVIDER WHO
MUST ALSO COMPLETE AND SIGN PART 7.
SHS will not accept “see attached” all dates must be written in. All titer reports
must be submitted with the Immunization Record form for proper documentation.
VARICELLA (chicken pox)
(1) (2)
or titer report submitted with form
HUMAN PAPILLOMAVIRUS (HPV)
(1) (2) (3)
Check One
HPV 4 HPV 9 HPV 4 HPV 9 HPV 4 HPV 9
HEPATITIS A (If Twinrix, see Part 5, Hepatitis B)
(1) (2)
or titer report submitted with form
Bexsero
Trumemba
MENINGOCOCCAL TYPE B (not MCV ACYW)
(1) ____________ (2) _____________ (3)_____________
Strongly recommended if living in a dorm or dorm like facility - will not document if type is unknown
PART 7. HEALTHCARE PROVIDER (RN, NP, MD, DO, PA)
INFORMATION AND SIGNATURE ALL INFORMATION REQUIRED, including provider credentials
Healthcare Provider Signature: ___________________________________________________
Printed Name and Credentials/Title:__________________________________________________________________________
Name of Practice: ________________________________________________________________________________________
Clinic Address: ______________________________________________________ Phone Number: ______________________
Date: ______________
Date of
Birth:
Date of
Birth:
Student Name:Student Name:Student Name: G #G #G #
Date of
Birth:
Heplisav
Heplisav
Must show proof of Tetanus/diphtheria/pertussis vaccine after age 11. If vaccine has expired (more than 10 years), also
show proof of tetanus vaccine (TD or Tdap) within the last 10 years.
Transcribed Records
Administered Vaccine (s)
11/12
Page 4 of 6
PART
PART 8: WAIVERS FOR HEPATITIS B AND MENINGOCOCCAL
8. WAIVERS FOR HEPATITIS B AND MENINGOCOCCAL VACCINES
WAIVER OF IMMUNIZATION AGAINST HEPATITIS B DISEASE
only if no previous record of vaccination
Hepatitis B is a serious liver disease caused by the hepatitis B virus (HBV). HBV infection can affect
people of all ages and lead to liver disease. The virus is found in the blood and body fluids of infected
people it is most often spread among adults through sexual contact or by sharing needles and other drug
paraphernalia with an infected person. HBV can also be spread in households of HBV-infected persons or
by passage of the virus from an HBV-infected mother to her infant during birth. Hepatitis B can be a silent
disease, often infecting many people without making them feel sick. Unfortunately, 30 percent of those
infected with HBV are not aware that they are carriers and can infect others. Hepatitis B symptoms might
include loss of appetite, fatigue, stomachache, nausea and vomiting, yellowing of the whites of the eyes
(jaundice), and/or joint pain. Vaccination can help prevent people from contracting hepatitis B. The HBV
vaccine is 96 percent effective following a series of three shots over a six-month period. The most
common side effect of the vaccine is soreness at the injection site. Vaccine recipients cannot get the
disease from the vaccine.
I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious
disease. If in the future I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination
series at anytime. I have received and reviewed the information regarding hepatitis B and the availability
and effectiveness of the hepatitis B vaccine. I have chosen not to be vaccinated (or I am unable to provide
current vaccination records) against hepatitis B.
Student Signature
Date
If student is a minor, Parent/Guardian
Date
Signature required also
WAIVER OF IMMUNIZATION AGAINST MENINGOCOCCAL DISEASE
only if no previous record of vaccination
Meningitis is an inflammation of the linings of the brain and spinal cord. It is caused by bacteria called
Neisseria meningitidis. The bacteria are transmitted through air-borne droplets of respiratory secretions
and by direct contact with infected persons. Although bacterial meningitis occurs rarely and sporadically
throughout the year, increased outbreaks occur among college students, especially those who live in
residence halls. Early symptoms of meningococcal disease include fever, severe headache, stiff neck,
rashes, and exhaustion. If not treated early, meningitis can lead to severe and permanent disabilities or
even death. A vaccine is available that protects against four strains of the bacteria that cause meningitis in
the United States: types A, C, Y, and W-135. These types account for nearly two-thirds of meningitis
cases among college students. The vaccine is safe, with mild and infrequent side effects, such as redness
and pain at the injection site lasting up to two days. The vaccine is 85 to 100 percent effective.
I have received and reviewed the information regarding meningococcal disease and the availability and
effectiveness of the meningococcal vaccine. If in the future I want to be vaccinated with meningococcal
vaccine, I can receive the vaccination at anytime. I have chosen not to be vaccinated against
meningococcal disease.
Student Signature
Date
If student is a minor, Parent/Guardian
Date
Signature required also
Date of
Birth:
Date of
Birth:
Student Name:Student Name:Student Name: G #G #G #
Date of
Birth:
11/12
Page 5 of 6
Residential FLU Requirement
shs.gmu.edu/immunizations
Visit the website shs.gmu.edu for office hours and more information.
Upload to Patient Portal (preferred method): https://gmu.medicatconnect.com
SUBMIT supporting documentation (DO NOT FAX OR EMAIL)
Mail records: George Mason University Student Health Services 4400 University Drive, MS 2D3, Fairfax, VA 22030 Students
can check record status in the portal.
Print services (on campus) offers scanning service for students.
Legal
FLU Requirement - TO BE COMPLETED BY A HEALTHCARE PROVIDER
MUST ALSO COMPLETE AND SIGN below. SHS will not accept “see attached” all dates must be written in.
Legal
Student G#
Last Name
First Name
U.S. Address
City
State
Zip Code
Date of Birth
Home Phone
Cell Phone
Flu Vaccine _______________(date)
Required for all students living on campus
.
Vaccine must be received after July 1,
of the current year.
Transcribed Records
Administered Vaccine (s)
Printed Name and Credentials/Title:
Name of Practice:
Clinic Address: Phone Number:
Healthcare Provider Signature: ______________________________________________________ Date: __________________
Medical: Mason Medical Exemption Form completed and signed by healthcare provider. Upload to the patient portal.
ALLOWABLE EXEMPTION: DO NOT APPLY TO TUBERCULOSIS SCREENING/TESTING
11/12
Page 6 of 6
PERSONAL INFORMATION - TO BE COMPLETED BY ALL STUDENTS, PRINT LEGIBLY
Select state
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Immunization Record Form (George Mason University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document