Required Immunization Form

Required Immunization Form

2020-2021
This form must be completed in ENGLISH and signed by (1) student (parent or guardian if the student is under age 18.) The form should also be signed by a medical provider. If the form is not signed by a medical provider, you MUST submit: (a) a physician’s certificate; (b) immunization records forwarded from another school or postsecondary institution; (c) a certificate record maintained by the student or parent of the student showing the month/day/year in which each dose of vaccine was administered; or (d) evidence of having met alternative criteria.
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
SMWC ID:*
Are you an International Student?*
Required Immunizations
Tetanus-Diphtheria (TD/Tdap): Booster must be within the last 10 years

Date:   _____/_____/_____

MMR (Measles, Mumps and Rubella): Two doses required

Dose #1____/_____/____ Dose #2____/____/___

Varicella (chickenpox) Dose #1 ___/___/___ Dose #2 ___/___/___

Or, Date of Disease ___/____/____

Hepatitis A #1 ___/___/___ #2___/___/____

Hepatitis B #1___/___/___ #2___/___/___ #3___/___/___

Meningococcal (MCV4) Dose #1___/___/___ Dose #2 ___/___/___

Polio Series Date Completed___/___/___

MenB-FHbp (Trumenba) OR  MebB-4c (Bexsero)

Two doses: initial and six months later Two doses: at least one month apart

Dose #1 __/ __/ __ Dose #1 __/ __/ __

Dose #2 __/ __/ __ Dose #2 __/ __/ __

Please List all other vaccinations:______________________________________________________

_________________________________________________________________
International Students

All International students are required to submit Tuberculosis (TB) screening information to SMWC. Students who are US citizens are not required to subit this information.

TB Skin Test must be performed AFTER arrival in the US (in compliance of State and Federal law).

PPD Date Administered____/____/____ Date Read____/____/____ Result____mm Initials of recorder______

BCG Date (if applicable): ____/____/____

**Chest X Ray or QuantiFERON-TB Gold required only if skin test is positive

Chest X Ray Date____/____/____ Result_____________________________________________________

QuantiFERON –TB Gold Date____/____/____ Result__________________________________________
Physician's Signature

To my knowledge the above information has been filled out completely and accurately.
Physician's Signature: _________________________________________

Date: __________________

Completed forms should be mailed, faxed or emailed to:

Saint Mary-of-the-Woods College

Health Services Center

1 St. Mary of Woods Coll

Saint Mary of the Woods, IN 47876-1099 USA

Fax: (812) 535-1162

Email: vax@smwc.edu

Questions: (812) 535-5200
Should be Empty:

Required Immunization Form

Required Immunizations

Physician's Signature