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Immunization-Form-International-Students-updated

The document is an International Student Immunization Verification Form for Montclair State University, requiring healthcare providers to complete and sign it. It outlines immunization requirements for MMR, Hepatitis B, and Meningitis, as well as strongly recommended vaccines like COVID-19 and others. Students must upload the completed form and enter immunization dates into the MyHealth portal.

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anrisaakian93
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15 views

Immunization-Form-International-Students-updated

The document is an International Student Immunization Verification Form for Montclair State University, requiring healthcare providers to complete and sign it. It outlines immunization requirements for MMR, Hepatitis B, and Meningitis, as well as strongly recommended vaccines like COVID-19 and others. Students must upload the completed form and enter immunization dates into the MyHealth portal.

Uploaded by

anrisaakian93
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MONTCLAIR STATE STUDENT HEALTH CENTER

INTERNATIONAL STUDENT IMMUNIZATION VERIFICATION FORM (updated 5/21/24)

STUDENT NAME (Last, first): ________________________ Date of birth: ______________

CWID: _____________

INSTRUCTIONS: Your healthcare provider must complete, sign and stamp this form. It will
become your reference & verification document. The MyHealth portal cannot read images. You
must also type the dates into the portal’s online immunization form. Scan & upload documents
into the portal. Blood test results (titers) are accepted in lieu of immunization dates.

MMR REQUIREMENT (Full-time and Part-time students) - Measles-Mumps-Rubella (MMR)


MMR dose 1st date: ___________ (date must be after first birthday)
MMR dose 2nd date : ___________
-OR-

Individual Measles, Mumps, and Rubella Vaccines:


Measles 1st dose: __________ (date must be after first birthday)
Measles 2nd dose: _________
Mumps 1st dose: __________ (date must be after first birthday)
Mumps 2nd dose: _________
Rubella Single dose: __________ (date must be after first birthday)

-OR-

MMR Titers (Lab results must be positive or negative. Equivocal results not accepted.)
Measles lab date: __________ Result (circle one): POSITIVE NEGATIVE
Mumps lab date: __________ Result (circle one): POSITIVE NEGATIVE
Rubella lab date: _________ Result (circle one): POSITIVE NEGATIVE

HEPATITIS B REQUIREMENT: (Full-time students)


Date for dose 1: __________ Date for dose 2: __________ Date for dose 3: __________
Dose 2 = 4 wks after dose 1. Dose 3 = 16 wks after dose 1 + 8 wks after dose 2.

-OR-
HepB Titers: date _____________ Result (circle one): POSITIVE NEGATIVE

MENINGITIS REQUIREMENT (SeroGroup ACWY):


Students under 19yrs (Commuter & Resident, 2 doses w/2nd dose given after 16th birthday)
Dose 1 ___ __ Dose 2__ ______
Students 19yrs + older (Resident, 1 Dose after 16th b’day + w/in last 5yrs) Date: __________
STUDENT NAME (Last, first): ________________________ Date of birth: ______________

CWID: _____________

STRONGLY RECOMMENDED (Not required)

COVID-19 (Residential students) Manufacturer name: ___________________________

Dose 1 _____________ Dose 2_____________ Add’l doses _______________________

Meningococcal B Vaccine: Serogroup B - Bexsero


Date for dose 1: __________ Date for dose 2: __________

Meningococcal B Vaccine: Serogroup B - Trumenba (2 or 3 dose schedule)


Date for dose 1: __________ Date for dose 2: __________ Date for dose 3: __________

Varicella (Chickenpox) Vaccine:


Date of dose 1: __________ Date of dose 2: __________

Tdap (tetanus, diphtheria and pertussis) Vaccine (this is not the same as DTap):
Date of last Tdap dose: __________

Td (tetanus, diphtheria) Vaccine:


Date of last Td dose: __________

Hepatitis A (Hep A) Vaccine:


Date of dose 1: __________ Date of dose 2: __________

Human Papilloma (HPV) Vaccine: Manufacturer name: ______________________


Date of dose 1: __________ Date of dose 2: __________ Date of dose 3: __________

Pneumococcal Vaccine 13-Valent: Pneumococcal Vaccine 23-Valent:


Date of dose 1: __________ Date of dose 1: __________

TST/PPD (Mantoux): Date: __________ Reaction: _____ Negative _____Positive


_____Induration _____mm

Chest X-ray: Date: __________ Result: ___________________________________


INH Therapy Start Date: __________ Stop Date: __________

HEALTHCARE PROVIDER

Name: __________________________________________ Title: ______________________


Stamp:

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