Fillable Section I To Be Completed by Student

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Section I To Be Completed by Student

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Page 1 of 2
Immunization Documentation
Immunization documentation is due by July 25 for fall semester and January 25 for spring semester.
All incoming students, including transfer and graduate students, are required to submit immunization records. This form
must be completed and signed by a licensed healthcare provider (physician, nurse practitioner, physician’s assistant, or
registered nurse). Official documentation of your immunization records is an acceptable alternative to this form.
All documentation must include your name and date of birth and be signed and legible in order to be accepted.
All documentation must be in English.
Forms should be uploaded to your UD Health Portal at www.udel.edu/studenthealth or faxed to 302-831-6407.
Section I – To Be Completed by Student
Name:
Last
First
Middle
Date of Birth:
________/________/________
UDID #:
MM DD YYYY
Country of Birth:
/
MM/YYYY
Section II – To Be Completed by Medical Provider
A. Required Vaccines
Required Vaccines
MMR
Measles, Mumps,
Rubella
For students born after
1956
Two doses after age
12 months at least
28 days apart or
titers are required
1. ____/____/____
MM DD YY
2. ____/____/_
___
MM DD YY
MMR Titers
Lab Results must be
submitted for results
to be accepted
Measles ___/___/___
MM DD YY
☐Immune
☐Non-Immune
Mumps
___/___/___
MM DD YY
☐
Immune
☐
Non-Immune
Rubella
___/___/___
MM DD YY
☐Immune
☐Non-Immu
ne
Meningococcal
ACWY*^
Strongly recommended for all
students. Required for all first
year students living in on-
campus housing
☐Menactra
☐MenQuadfi
☐Menveo
☐Menomune
1. ____/____/____
MM DD YY
☐Menactra
☐MenQuadfi
☐Menveo
☐Menomune
2. ____/____/____
MM DD YY
*At least one dose
must be administered
on or after 16 years of
age
COVID19
Primary Series
You are not
considered fully
vaccinated until 14
days after you finish
your series
☐Pfizer
☐Moderna
☐Janssen/J&J
☐Other:
_______________
1. ____/____/____
MM DD YY
2. ____/____/_
___
MM DD YY
Booster #1
Booster #2
____/____/____
MM DD YY
____/____/____
MM DD YY
☐Pfizer ☐Janssen/J&J ☐Pfizer ☐Janssen/J&J
☐Moderna
☐Other:
____________
☐Moderna
☐Other:
____________
^Additional information regarding Meningococcal Disease can be found here: https://sites.udel.edu/studenthealth/meningitis/
Continued on next page – Practitioner Signature Required
or
Rev 6/22
C-IM/01
Page 2 of 2
B. Recommended Vaccines
These vaccines are not required for admission to the University but are recommended. They may be required for
specific academic programs.
Recommended
Vaccines
Hepatitis A
☐
Hepatitis A
☐
Combined A/B
>
1. ____/____/____
MM DD YY
2. ____/____/
____
MM DD YY
>
3. ____/____/____
MM DD YY
Hepatitis B
☐
3 Dose Series
☐2 Dose Series
☐
Combined A/B
1. ____/____/____
MM DD YY
2. ____/____/
____
MM DD YY
3. ____/____/
____
MM DD YY
Hep B Surface
Antibody Titer
Must submit lab report
____/____/____
MM DD YY
☐Immune
☐Non-Immune
HPV
☐
HPV9
☐HPV4
☐
Cervarix
1. ____/____/____
MM DD YY
2. ____/____/
____
MM DD YY
3. ____/____/
____
MM DD YY
Meningitis B
☐
Trumenba
+
☐
Bexsero
1. ____/____/____
MM DD YY
2. ____/____/
____
MM DD YY
+
3. ____/____/____
MM DD YY
Polio
Completed
Primary Series?
☐Yes ☐No
Date Completed:
____/____/__
__
MM DD
YY
Booster
____/____/____
MM DD YY
Tetanus
Completed
Primary Series?
☐Yes
☐No
Date Completed:
____/____/__
__
MM DD
YY
Booster
☐Tdap
☐Td
____/____/____
MM DD YY
Varicella
1. ____/____/____
MM DD YY
2. ____/____/
____
MM DD
YY
Antibody T
iter
Must submit lab report
____/____/____
MM DD YY
☐Immune
☐
Non-Immune
For religious or medical exemptions, please view the instructions provided in your UD Health Portal and complete the required documentation.
C. Completing Medical Provider Information
Name:
Credentials:
Signature:
Date:
Address and
Phone
Number:
Rev 6/22
C-IM/01
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Section I To Be Completed by Student

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Completed 17 June 2022

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