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 [email protected].