Wisconsin State Law (Assembly Bill 344) requires students to sign an acknowledgement statement related to
Hepatitis B and Meningitis. Please follow the links to read the Vaccine Information Statements regarding
Hepatitis B and Meningococcal disease
.
My signature below verifies my review of the Meningococcal and Hepatitis B
information statements.
My signature also indicates that my vaccination history below is true and correct.
Student’s Name (please print): ______________________________________ Date of Birth: ___________________
Student’s Signature: ______________________________________________ Date: __________________________
REQUIRED
VACCINES
Type
Dose
Date
(MM/DD/YY)
RECOMMENDED VACCINES
AND TESTS
Type
Dose
Date
(MM/DD/YY)
Diphtheria
Tetanus
Pertussis
(DTP)
Tetanus/Diphtheria
(Adult) (TD)
1
TB skin test
Chest X-ray for reactive TB test
or Quantiferon Gold
Reactive Non reactive
2 _____MM
3 Results
4
5
Hepatitis A
1
(6) 2
Td 1 1
Td 2
Hepatitis B
2
3
Polio
(specify OPV or IPV)
Measles/Mumps/Rubella
(MMR)
1
2 1
3
Meningococcal
(2)
4
(5)
Other Vaccines Received
1
2
Varicella (Chicken Pox)
or date of disease
1
(2)
Must be completed by ALL students
Students must have required vaccinations or schedule them with the Student Health Center.
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