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Important! Do Not Delay!
The UCF Mandatory Immunization Health History Form is
REQUIRED prior to Class Registration at UCF
Health Information Management Department
University of Central Florida 4098 Libra Drive, Orlando FL 32816-3333
PHONE: 407.823.3707 or 407.823.2119
Please read this entire document carefully as incorrect form
submissions may result in delays!
1. UCF will accept official state immunization forms, issued by local health departments,
stamped
high school transcripts, military immunization forms, and physician's office records (
signed and stamped
) in
conjunction with completing the UCF Mandatory Immunization Health History form. If you have supporting
documentation, attach it to a completed UCF Immunization form. The UCF immunization form is available on
the UCF Student Health Services
website along
with the link you will need to upload your documents at
https://studenthealth.ucf.edu/immunizations.
2. The Advisory Committee on Immunization Practices (ACIP) has recommended that persons 16-23 years
of age receive vaccinations for meningococcal meningitis. By action of the Florida State University
System Board of Governors, this recommendation is supported by the policy effective July 1, 2008 that
"all NEW matriculating students must provide documentation of vaccinations against meningococcal
meningitis and hepatitis B or provide a signed waiver for each declined vaccination." Please note: All
students regardless of age must either submit proof of having received this vaccine after the age of
16 or sign the waiver.
3. Except where noted, students enrolled in strictly online only programs are not required to submit proof of
immunizations; however, all students must submit the UCF Mandatory Immunization Health History form
along with the completed waivers for Meningitis and Hepatitis B.
Click here to jump to the UCF Online section (page 4) for more information and instructions.
4. Active-duty military and veterans may complete the waiver section of the immunization form if
documentation of immunizations is unavailable at the time of registration. Proof of military
service is
required (DD 214 or military ID card).
Please note: This policy does not apply to
dependents.
Click here to jump to the form on page 5 for more information and instructions.
Revised 10/2021
Accurate and complete immunization information is required for registration at UCF. Incomplete information may result in your registration
being delayed or even blocked. Please follow these directions:
Name/phone, etc. Print all information legibly. Provide 7-digit UCF ID number
Section A: Required Immun
izations. Required for EVERYONE born after Dec. 31, 1956.
COVID-19 can have serious, life-threatening complications, and there is no way to know how COVID-19 will affect you. While there is no
federal or state mandate to receive the COVID-19 vaccine, all eligible individuals are strongly encouraged to get vaccinated as soon as they are
able. In addition to protecting each recipient against infection, it is essential that a large enough percent of the population receives the vaccine in
order to achieve “herd immunity” to prevent continued spread of the virus causing COVID-19. We must each play our part in this process, as we
have in the past with vaccines to eliminate the threat of polio, measles and other viral infections. None of the COVID-19 vaccines currently being
administered in the U.S. use the live virus that causes COVID-19. The goal of vaccination is to teach our immune systems how to recognize and
fight the virus that causes COVID-19. Sometimes this process can cause symptoms, such as fever. These symptoms are normal and are a sign that
the body is building immunity.
Pfizer offers 2 doses for those 12 years and older given 21 days apart with a booster after six months. Moderna offers 2 doses 28 days apart.
Johnson and Johnson offers 1 dose for those 18 and older.
1. MMR: This combination vaccine is often given because it protects from measles, mumps, and rubella. Two doses are required for entry into
UCF. (1) The first dose must have been received at 12 months of age or later and in 1971 or later. (2) The second dose must have been received
at least 30 days after the first dose as per CDC guidelines.
*OR*
Measles (Rubeola): Two doses are required. (1) The first dose must have been received at 12 months of age or later and in 1968 or later. (2) The
second dose must have been received at least 30 days after the first dose.
*AND*
Rubella (German Measles): One dose is required at 12 months of age or later and in 1969 or later.
2. Hepatitis B (HBV) immunization: You are encouraged to receive this series. Students in many Academic Health Programs are required to
have the HBV series. Students wishing to decline this vaccine must read the information provided below. Signing a waiver indicates that you
understand
the possible risk involved in not receiving this immunization. If you are under the age of 18, a parent or guardian must sign the
waiver for you. The vaccine is usually administered as a three-dose series on a 0-, 1-, and 6-month schedule. The 2nd dose should be given 1
month after the first dose; the third dose should be given at least 2 months after the second dose and at least 4 months after the first dose. The
Hepatitis B two-dose schedule "Recombivax" should be supported by an official document and the 2nd shot is administered 4-6 months after the
first one. * Twinrix (Hepatitis A/B) series may be used as a substitute for the Hepatitis B series.
Waiver Statement-Hepatitis B: Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver
cancer, liver failure, and even death. This disease is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis
B viral infection. A series of three doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if
only one or two have been received. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases. For more
specific information about Hepatitis B disease and vaccines, please visit UCF Student Health Services website at:
https://studenthealth.ucf.edu/immunizations.
3. Meningococcal meningitis vaccines: The Advisory Committee on Immunization Practices (ACIP) currently recommends these vaccines for
persons 16-23 years of age. The ACIP also recommends a booster dose of meningococcal vaccine for students who received their primary dose
before the age of 16 years. Students wishing to decline the vaccine must first read the information in the box below. Signing the waiver indicates
that you understand the possible risk involved in not receiving this vaccine. If you are under the age of 18, a parent or guardian must sign the
waiver for you.
Waiver Statement-Meningococcal Meningitis: College students, especially freshman living in residence halls, are at an increased risk for
contracting meningococcal disease. The bacterial form of this disease can lead to serious complications such as swelling of the brain, coma, and
even death within a short period of time. FDA approved vaccines are currently available that decrease a person's risk of acquiring meningococcal
meningitis. There are (5) different serotypes (A, B, C, Y and W-135). Two conjugate vaccines (MCV4) offer protection against serotypes (A, C, Y
and W-135), and two vaccines cover the B strain of the bacteria. For more specific information about meningococcal meningitis and college
student risks, please visit UCF Student Health Services website: https://studenthealth.ucf.edu/immunizations.
Section B: Recommended Immunizations for Good Health
• Td (Tetanus)/Diphtheria or/and Tdap (Tetanus/Diphtheria/Pertussis) - Booster shot within last 10 years. Space is provided to record this
information.
• Varicella (Chicken pox) - History of disease or vaccine is acceptable. Indicate the date you had chicken pox. OR: Provide proof of two doses of
Varivax. OR: Provide results of a blood test on a laboratory form.
• Hepatitis A, HPV, Polio, Influenza, Other - In the boxes provided in this section you may also list any additional vaccines that were
administered. These are not required.
Section C: Identify if you have Type (1) Diabetes and whether or not you are interested in participating in the UCF Student Health Services
program to help students with Type (1) Diabetes.
Section D: A signature of parent or guardian MUST be included on the form if the student is under the age of 18.
For more Helpful Tips to complete the immunization form and for information about valid exemptions, check out UCF Student Health Services
website at: https://studenthealth.ucf.edu/immunizations.
Ma
ndatory Immunization
Health History Form
Health Information Management Department
University of Central Florida
4098 Libra Drive, Orlando FL 32816-3333
PHONE: 407.823.3707/2119
https://studenthealth.ucf.edu/immunizations
Name:________________________
Date of Birth: _________UCF ID: __________________
Phone: ____________________Orientation Date:_________
Section A: Required Immunizations
WAIVER: I have read the information provided about Hepatitis B and Meningococcal Meningitis/MCV4. By signing below, I acknowledge I am declining
both, which are highly recommended, but not required.
______________________________________
_____________________ ______________
_______________________________ ___________ OR
Signature of student DATE
Signature of parent/guardian if student under 18
Relationship to student DATE
Section B: Recommended Immunizations for Good Health (NOT REQUIRED)
Month/Day/Year
Month/Day/Year
Month/Day/Year
Td (Tetanus/Diphtheria)
AND/OR Tdap
(Tetanus/Diphtheria/Pertussis)
Varicella (Chicken Pox)
History of disease:
Hepatitis A
DO NOT WRITE HERE
HPV (Gardasil)
Polio (last date)
Meningococcal B Serogroup
(Bexsero/Trumenba)
Covid-19 (Johnson & Johnson, Moderna,
Pfizer)
DO NOT WRITE HERE / DO NOT WRITE HERE / DO NOT WRITE HERE
An official stamp from a doctor's office, clinic, or Health Department AND an authorized signature must appear on this form or on the
official document(s) attached in order to be accepted.
___________________________________
______________ ______________________________________ ________________
Official Stamp Here
Physician or Authorized Signature Date
DO NOT WRITE HERE / DO NOT WRITE HERE / DO NOT WRITE HERE
DO NOT WRITE HERE / DO NOT WRITE HERE / DO NOT WRITE HERE
SECTION C: Type 1 Diabetes
Do you have type 1 Diabetes? If yes, please enter your student email to receive information about the student support group?
Email Address _________________________________________________________
SECTION D: MEDICAL CONSENT IF UNDER 18 YEARS O
LD
I HEREBY AUTHORIZE Student
Health Services and the University Counseling Center at the University of Central Florida to employ diagnostic procedures and to render
treatment or medical, dental, surgica
l, psychological, or psychiatric care deemed necessary to the health and well-being of my student. I grant permission for the transfer of my
student to an accredited hospital or other care facility if deemed necessary by the medical or mental health provider and for my student to sign any necessary consents.
___________________________________ ____________________________ ____________________
Signature of parent/guardian Relationship to student Date
Required for all students born after 12/31/1956
Month/Day/Year
Month/Day/Year
Month/Day/Year
Titer Date & Result
1. MMR (2 doses after 1st birthday & at least 30
days apart in 1971 or later)
DO NOT WRITE HERE
Please attach lab report
OR Measles (two doses required given in 1968 or
later)
DO NOT WRITE HERE
Please attach lab report
Rubella (one dose required given in 1969 or later)
DO NOT WRITE HERE
Please attach lab report
2. Hepatitis B (OR sign waiver below)
Please attach lab report
3. MeningococcalMeningitisVaccine/MCV4:
(Menactra/Menveo)
(must be given after the age of 16 OR sign waiver
below)
Booster needed if 1st
dose is given before
the age of 16
DO NOT WRITE HERE
UCF Online Students
As a UCF Online student, you are only required to complete the UCF Mandatory Health History form. Please
follow these TWO steps below to complete your required submission.
1. Access the form, and complete Section A:
a. Complete the form provided (page 3). This is a fillable/editable PDF form. You can either type
on it and save to your computer, or you can print, fill it out by hand, and then scan (or take a
photo).
2. Submit your completed “Section A” form to Med+Proctor
a. Go to: https://studenthealth.ucf.edu/immunizations/
b. Click the “Register for Med+Proctor Account” button.
i. You will use your UCF NID and password. This ID contains 2 letters and 6 numbers. If
you do not know your UCF NID, please visit my.ucf.edu and click on “What is my NID?”
underneath the sign in button. You can click “Password Reset” if you do not know your
password.
c. Submit your form
i. Please allow up to 72 hours for Med+Proctor to confirm via your email on file that your
information has been verified for your hold to be released.
Except where noted, UCF Online students are not required to submit proof of immunizations.
However, UCF Online students must still submit the UCF Mandatory Immunization Health History
form, along with the completed waivers for Meningitis and Hepatitis B.
NOTE: This option does not apply to students who simply chose to take online courses. Rather, this
is an option available for UCF Online students only! UCF Online is a specific program at UCF
designed for fully online students with no option to take classes on campus. Students are admitted
into UCF Online at the time of application. If you did not admit into the UCF Online program,
please return to the start of this form, and complete ALL required immunization procedures!
If you are unsure if this applies to you, please immediately contact a UCF Online Success Coach at
855-903-8576 or visit www.ucf.edu/online/.
UCF Active-Duty Military and Veteran Exception
As active-duty military or veteran, you are only required to complete the UCF Mandatory Health History form.
Please follow these TWO steps below to complete your required submission.
1. Access the form, and complete Section A:
a. Complete the form (page 3). This is a fillable/editable PDF form. You can either type on it and
save to your computer, or you can print, fill it out by hand, and then scan (or take a photo).
2. Submit your completed “Section A” form to Med+Proctor
a. Go to: https://studenthealth.ucf.edu/immunizations/
b. Click the “Register for Med+Proctor Account” button.
i. You will use your UCF NID and password. This ID contains 2 letters and 6 numbers. If
you do not know your UCF NID, please visit my.ucf.edu and click on “What is my NID?”
underneath the sign in button. You can click “Password Reset” if you do not know your
password.
c. Submit your form
i. Please allow up to 72 hours for Med+Proctor to confirm via your email on file that your
information has been verified for your hold to be released.
Active-duty military and veterans may complete the waiver section of the
immunization form if documentation of immunizations is unavailable at the
time of registration. Proof of military service is required (DD 214 or military
ID card); however, all students must submit the Mandatory Immunization
Health History form along with the completed waivers for Meningitis and
Hepatitis B. The waivers include signing and dating the statement below
Section A. This policy does not apply to dependents (spouses, children, etc.).
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Completed 25 June 2022

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