Date of Entry ____/_____ Date of Birth _____/_____/_____ School ID# ________________________________________ Mo Yr Mo Day Yr
PART II - TO BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER OR A COPY OF YOUR OFFICIAL IMMUNIZATION HISTORY (Please fill out Part I if you are attaching photocopied records).All information must be in English.
REQUIRED IMMUNIZATIONS
1. M.M.R. (Measles, Mumps, Rubella) (Two doses required at least 28 days apart for students born after 1956 and all health care professional students.)
A. Dose 1 given at age 12-15 months or later.…………………………………………………………….#1 ____/____/____ Mo Day Yr B. Dose 2 given at age 4-6 years or later, and at least one month after first dose ………………..………#2 ____/____/____ Mo Day Yr
OR
C. MMR surface antibody Result Reactive _____ Non-reactive _____.………………… .____/____/____ Mo Day Yr
2. TETANUS, DIPHTHERIA, PERTUSSIS (Td or Tdap booster in the last ten years meets requirement.)
Date of most recent booster……………………………………………………………………………………..... ____/____/____
