UAB Student Health & Wellness Immunization Form
Non-Clinical Domestic Students
This form is required to be submitted through . *Copies of your original immunization records will also be
accepted in place of this form.
NAME: ___________________________________________________________ DATE OF BIRTH: (mm/dd/yyyy): _______________
ADDRESS: ___________________________________________________________________ PHONE: _________________________
PROGRAM OF STUDY: _________________________________________________BLAZERID:_______________________@UAB.EDU
IMMUNIZATION HISTORY MUST BE COMPLETED BY A HEALTH CARE PROVIDER
st
MMR- Measles, Mumps, and Rubella: All students born in the U.S. after January 1
, 1957 must satisfy this requirement, either by
two vaccine doses against each of the three diseases or laboratory evidence of immunity to all three diseases.*If born in the U.S.
st
prior to January 1
, 1957, student is exempt.
1.
EITHER
Two doses of MMR vaccine:
Date: _____/_____/_____
Date: _____/_____/_____
OR
Two doses of each vaccine component:
Measles
Date: _____/_____/_____ Date: _____/_____/_____
Mumps
Date: _____/_____/_____ Date: _____/_____/_____
Rubella
Date: _____/_____/_____ Date: _____/_____/_____
OR
Laboratory evidence of immunity to all three diseases:
Measles
Date: _____/_____/_____ Result: _______________
Mumps
Date: _____/_____/_____ Result: _______________
Rubella
Date: _____/_____/_____ Result: _______________
*If any laboratory titers are non-immune, 1 booster dose is required.
Date: _____/_____/_____
2. Tdap- Tetanus, Diptheria, Acellular Pertussis: All students must have had one dose within the past 10 years.
Date: _____/_____/_____
st
3. Varicella (chickenpox): All students born in the U.S. after January 1
, 1980 must have documented history of Varicella, a positive
st
Varicella antibody titer, or two doses of Varicella vaccines given at least 28 days apart. *If born in the U.S. prior to January 1
,
1980, student is exempt.
EITHER
History of Varicella (chickenpox or shingles):
Yes: _____ No: _____
Date: _____/_____/_____
OR
Varicella antibody titer
Positive: _____ Negative: _____
Date: _____/_____/_____
OR
Varicella vaccination Dose 1: _____/_____/_____
Dose 2: _____/_____/_____
*If Varicella antibody titer is negative or equivocal, two repeat vaccinations are required.
Varicella vaccination Dose 1: _____/_____/_____ Dose 2: _____/_____/_____
4. Meningococcal: All students 21 and younger are required to show documentation of a meningitis vaccine given on/after their
th
16
birthday. Students age 22 and older are exempt.
Date: _____/_____/_____