AUGUSTA UNIVERSITY CERTIFICATE OF IMMUNIZATION

Name: ____________________________________________________ ____________________________________________________ ______________

Last First M.I.

Date of Birth: _______/________ /____________ Gender: Male Female Pounce ID# _______________________________________

Address: ______________________________________________________________________________________________________________________________

Street City State ZIP

You must have your health care provider complete and sign this form, and submit your records prior to the start of class. All information must be in English.

Please follow the directions at http://www.augusta.edu/shs/immunizations.php to submit your record.

I understand that FAILURE to meet GRU Immunization requirements may result in my DISENROLLMENT from Augusta University.

Student Signature: _________________________________________________ Date: __________________________________

IMMUNIZATION INFORMATION

Vaccine Date

MM/DD/YYYY

Date

MM/DD/YYYY

Date

MM/DD/YYYY

MMR * / / / /

Measles * / / / /

Mumps * / / / /

Rubella

(Before age 13) / /

Varicella ***

(Before age 13)

/

/

/

/ Or History of Chickenpox:

/ /

TDaP (must be administered

after 6/10/2005)

/

/ If TDaP is > ten years old,

date of last Tetanus booster

/ /

Hepatitis B ** / / / / / /

2 dose series

3 dose series

TB Screening Completion of TB Screening Questionnaire is required ANNUALLY. See attached document.

Meningococcal Required for students living

on campus

/

/

/

/ Proof of immunization

must be submitted to

GRU campus housing.

* Not required if born before 1957

** Only required of students who are 18 years of age or younger at the time of matriculation

*** Not required if born in the USA before 1980

STRONGLY RECOMMENDED IMMUNIZATIONS

PERMANENT ORTEMPORARY IMMUNIZATIONEXEMPTION - A STATEMENT FROM YOUR HEALTHCARE PROVIDER IS REQUIRED

EXEMPTIONS: Check the appropriate box, sign and date if you are claiming exemption of the immunization requirement for one of the following reasons:

I affirm that the immunizations, required by the University System of Georgia, are in conflict with my religious beliefs. I understand I am subject to

exclusion in the event of an outbreak of disease for which immunization is required.

I declare that I am enrolling in ONLY courses offered through distance learning. I understand that if I register for a course offered on campus or at a

campus managed facility that this exception becomes void and I will be excluded from class until I provide proof of immunizations.

Student Signature: _____________________________________________________________________________ Date: ________________________________

CERTIFICATION OF HEALTHCARE PROVIDER (This information is required)

Name: __________________________________ _ Signature: Date: ________/_______/_________

Address: _____ Phone Number: ___________________________________

Vaccine Date

MM/DD/YYYY

Date

MM/DD/YYYY

Hepatitis A / / / / Influenza / / / /

Part I: Augusta University Tuberculosis (TB) Screening Questionnaire

Have you ever had close contact with persons known or suspected to have active TB disease? Yes No

Were you born in one of the countries listed below that have a high incidence of active TB

disease? (If yes, please CIRCLE the country, below) Yes No

Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus

Côte d'Ivoire Croatia Democratic People's Republic of

Korea Democratic Republic of the

Congo Djibouti Dominican Republic Ecuador

Japan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic

Republic Latvia

Nicaragua Niger Nigeria Pakistan Palau Panama Papua New Guinea Paraguay Peru

Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav

Republic of Macedonia

Belize Benin

El Salvador Equatorial Guinea

Lesotho Liberia

Philippines Poland

Timor-Leste Togo

Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad China Colombia Comoros

Eritrea Estonia Ethiopia Fiji Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia

Libyan Arab Jamahiriya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia (Federated States

of) Mongolia Morocco Mozambique Myanmar Namibia

Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Vincent and the

Grenadines Sao Tome and Principe Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa

Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Republic of

Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian

Republic of) Viet Nam Yemen Zambia Zimbabwe

Congo Iraq Nepal Sri Lanka

Have you had frequent or prolonged visits* to one or more of the countries listed above with a

high prevalence of TB disease? (If yes, CHECK the countries, above)

Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional

facilities, long-term care facilities, and homeless shelters)?

Have you been a volunteer or health-care worker who served clients who are at increased risk for

active TB disease?

Have you ever been a member of any of the following groups that may have an increased incidence

of latent M. tuberculosis infection or active TB disease – medically underserved, low-income, or

abusing drugs or alcohol?

Yes No

Yes No

Yes No

Yes No

Have you ever had a positive TB skin test or IGRA blood test? Yes No

The BCG vaccination is a vaccine for Tuberculosis that is typically given in foreign countries with a higher incidence of TB. Please visit

Have you had the BCG vaccination? Yes No http://www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm for more information regarding this vaccine.

Print Name Date of Birth / / Student ID

Signature Date / /

Please answer the following questions (circle your answer):

IMMUNIZATION REQUIREMENTS

PROOF OF IMMUNIZATION OR NATURALLY ACQUIRED IMMUNITY REQUIRED

Vaccine Requirement Required for:

Measles (Rubeola)

Two (2) doses of live measles vaccine (combined measles-mumps-

rubella or “MMR” meets this requirement), with the first dose at 12 months

of age or later and the second dose at least 28 days after the first dose OR

laboratory or serologic evidence of immunity

Students born in 1957 or later

Mumps Two (2) doses of the mumps vaccine with the first dose at 12 months of

age or later and the second dose at least 28 days after the first dose Students born in 1957 or later

Rubella (German Measles) One (1) dose at 12 months of age or later (MMR meets this requirement)

OR laboratory or serologic evidence of immunity.

Students born in 1957 or later

Varicella (Chicken Pox)

(2) doses spaced at least 3 months apart if both doses are given before

the student’s 13th birthday or 2 doses at least 4 weeks apart, if first dose

is given after the student’s 13th birthday or reliable history of varicella

disease (chicken pox) or laboratory/serologic evidence of immunity or

history of herpes zoster (shingles)

All U.S. born students born in 1980 or

later.

All foreign born students regardless of

year born

Tdap (must be

administered on or

after 6/10/2005)

One Tdap dose administered after 6/10/2005.

If TDaP is greater than 10 years old then a Td booster dose is

ALSO required.

All students

Hepatitis B

Three (3) dose hepatitis B series (0 ,1-2 and 4-6 months) OR Three (3)

dose combined hepatitis A and hepatitis B series (0, 1-2 and 6-12 months)

OR Two (2) dose hepatitis B series of Recombivax (0 and 4-6 months,

given at 11-15 years of age) OR laboratory or serologic evidence of

immunity.

Required for all students who will be 18 years

of age or less at the time of expected

enrollment.

Recommendation: It is strongly recommended

that all students, regardless of their age at

matriculation, discuss hepatitis B immunization

with their health care provider.

TB Screening Completion of Augusta University TB screening questionnaire is required

annually.

All students

Meningococcal quadrivalent

polysaccharide

One (1) dose meningococcal conjugate vaccine (preferred) OR 1 d o s e of

meningococcal polysaccharide within 5 years prior to matriculation (booster dose

required if first dose received before the age of 16) OR Signed documentation that

student (or parent or guardian if student is < 18 years old) has received and

reviewed information about the disease as required by O.C.G.A.§31-12-3.2

Newly admitted freshman or matriculated

students planning to reside in university

managed campus housing.

ADDITIONAL IMMUNIZATION RECOMMENDATIONS - NOT REQUIRED

Vaccine Recommendation

Influenza Annual vaccination at the start of influenza season (October-March)

Hepatitis A Two (2) dose hepatitis A series (0 and 6-12 months), OR Three (3) dose combined hepatitis A and

hepatitis B series (0, 1-2 and 6-12 months)

Other Vaccines

Other vaccines may be recommended for students with underlying medical conditions and students

planning international travel. Students meeting these criteria should consult with their physicians or

health clinic regarding additional vaccine recommendations.

Human Papillomavirus 3 dose HPV series. Dose #2 is given 4-8 weeks after dose #1 and dose #3 is given 6 months after dose

#1 (at least 10 weeks after dose #2)

EXEMPTIONS- ALL REQUESTS FOR RELIGIOUS OR ONLINE STUDENT EXEMPTIONS MUST BE SUBMITTED EACH SEMESTER.

EMAIL ANY QUESTIONS TO IMMUNIZATIONS@AUGUSTA.EDU.