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Immunization Form

The Immunization Form requires all students entering Auburn University at Montgomery to provide proof of vaccinations for Measles, Mumps, Rubella (MMR) and Tetanus, Diphtheria, and Pertussis. International students must also report to Student Health Services for a Tuberculosis Skin Test upon arrival. Optional immunizations are recommended but not required, and the form must be completed by a licensed healthcare professional.

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44 views1 page

Immunization Form

The Immunization Form requires all students entering Auburn University at Montgomery to provide proof of vaccinations for Measles, Mumps, Rubella (MMR) and Tetanus, Diphtheria, and Pertussis. International students must also report to Student Health Services for a Tuberculosis Skin Test upon arrival. Optional immunizations are recommended but not required, and the form must be completed by a licensed healthcare professional.

Uploaded by

Chinnu Chinnu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Immunization (Vaccination) Form

To ensure the health and safety of our campus, immunizations against communicable diseases are extremely important.
Vaccination against Measles, Mumps, Rubella (MMR) and Tetanus, Diphtheria and Pertussis is required of all students
entering Auburn University at Montgomery. This form must be completed and is the preferred document for proof of
immunizations. Take this form to a doctor or clinic to be completed. Also, upon arrival to the campus, international
students will be required to report to Student Health Services to receive a Tuberculosis Skin Test. The cost of this test is
$15.00. TB skin tests performed outside of the United States will not be accepted.

Name AUM Student Number


Last First Middle

Local Address
Street City State Zip Code

Cell Phone Number E-mail Address Date of Birth (MMDD/YYYY)

REQUIRED IMMUNIZATIONS (Vaccinations)


Tetanus, Diphtheria, Pertussis Vaccine (preferred). Students without previous documentation of a TDaP
vaccine should have one dose prior to entrance based on current guidelines. A DTaP will not be accepted.
Date of Tdap vaccine: / / (within the last 5 years).
D M Y

Measles, Mumps, Rubella (MMR) 2 separate vaccinations of the MMR, given at least 1 month apart is
required.
Auburn Montgomery University requires that all students born after 1956 must have had 2 doses of a measles containing
vaccine (MMR) prior to registration. One dose must have been after 1980. Lab antibody titers (IgG) for Measles,
Mumps and Rubella are acceptable. Please attach documentation to the back of the form.

Date of First Dose / / Date of Second Dose / /


D M Y D M Y

OPTIONAL IMMUNIZATIONS (These immunizations are not required by the university but are recommended
by the American College Health Association.)

Hepatitis B: / / / / / /
1st 2nd 3rd

Varicella (Chickenpox) Vaccine: / / / /


1st 2nd

Meningococcal (meningitis) Vaccine: / / / / (MCV4 preferred)


1st 2nd

I certify that the above dates and vaccinations are true.

/ /
Signature of License Health Care professional Date License Number or Office
Stamp

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