Immunization Record Instructions and Form

Please read these instructions before filling out the Immunization Record Form A. Tetanus-Diphtheria 1. Date of the Students last dose in the primary series of the DPT vaccine. 2. One dose of TDAP is required for all incoming students regardless of the date of the last tetanus containing vaccine. If the Tdap vaccine is not available in your country, please defer this immunization until the Students arrival on campus. Measles, Mumps, Rubella-Two doses of Vaccine-Required by Massachusetts State Law st 1. 1 dose given after 12 months of age nd st 2. 2 dose given at least one month after the 1 dose 3. Positive Measles, Mumps, Rubella lab titer must be included if dates of immunization are not available I. If you were born before 1957, this Immunization is not required. 4. Please use Section B II to document any Monovalent Measles, Mumps, and Rubella. Please note that a physician history of having had the diseases of Measles, Mumps, or Rubella does not meet the Massachusetts State Requirement. Only laboratory documentation (titer) showing immunity is acceptable in Massachusetts.
B.

C.

Hepatitis B-Three Doses of Vaccine-Required by Massachusetts State Law st 1. 1 dose given at an elected date nd st 2. 2 dose given one month after the 1 dose rd st nd 3. 3 dose given at least 4-6 months after the 1 dose and 8 weeks after the 2 dose. 4. The adolescent dose schedule given between the ages of 11 and 15 may be accepted. The dosage must be specified. 5. Please use Section H to document the combined Hepatitis A and B Vaccine. 6. Positive Hepatitis B lab titer must be included if dates of immunization are not available

D. Meningitis Immunization/Waiver-Required by Massachusetts State Law 1. MCV4-Tetravalent Conjugate Vaccine (Menatra or Menveo)-OR2. MPSV4-Tetravalent Polysaccharide Vaccine (Menomune) given after 09/01/2007 for Fall Entrants and 01/20/2008 for Spring Entrants.-OR3. Waiver Form-Please see the Massachusetts Department of Health Meningococcal Information and Waiver Form. The Massachusetts Department of Health recommends a booster dose of MCV4 for all Students who received the first dose of MCV4 before the age of 16. E. Varicella Vaccine, Proof of Immunity-Required by Massachusetts State Law 1. A positive history of the Chicken Pox, the date the Student had the disease must be included.-OR2. Positive Varicella Titer-Lab Report must be included if dates of disease are unavailable.-OR3. Two Doses of the Varicella Immunization st a. 1 dose given after 12 months of age nd st b. 2 dose given at least 1 month after the 1 dose-OR4. If you were born before 1980, this Immunization is not required.

For more information on Massachusetts Requirements please refer to the following links: http://www.mass.gov/eohhs/docs/dph/cdc/immunization/guidelines-ma-school-requirements.pdf Students requesting a medical exemption from the immunization requirements must provide documentation from their Health Care Provider. If a Student would like to request a religious exemption, please send an explanatory note to request religious exemption. Massachusetts State Law requires Students who have not been immunized to leave campus should an outbreak occur. Students identified, as contacts who do not meet the immunization requirements will be isolated or required to leave the campus for up to two weeks. Additional information regarding MGL Chapter 76, Sec. 15 and 15d can be found at: http://www.state.ma.us/legis/laws/mgl/mgllink.htm

Due Date: July 1, 2012-Fall Entrants December 1, 2012-Spring Entrants

Immunization Record-Page 1
Massachusetts state law requires proof of immunity prior to matriculation. Please use this form to record immunization dates. International students must provide an English transcript of immunization history. NAME_________________________________________________________________________________________________ Last First Middle Date of Birth

A. Tetanus-Diphtheria: Immunization required by Massachusetts State Law

1. Primary series of Tetanus-Diphtheria-Pertussis Immunization Date of Last Dose _____________
Mo Day Mo Day Year Year

2. Tdap required.._____________

B. Measles, Mumps, Rubella: Proof of Immunity/Immunizations required by Massachusetts State Law I. M.M.R (Measles, Mumps, Rubella): Trivalent-vaccine
1. Dose 1-Immunized at 12 months after birth or later.________________
Mo Day Year

2. Dose 2-Immunized at any time 1 month after dose #1.._______________

Mo Day Year

II. Monovalent Measles, III. Titers-SEE PAGE 2

Rubella, Mumps-SEE PAGE 2

C. Hepatitis B Vaccine: Three-dose series required by Massachusetts State Law

1. Dose #1 at elected date_______________._________________
Dose Dose Mo Mo Mo Day Day Year Year

2. Dose #2 at least 4 weeks after dose #1..______________............._________________ 3. Dose #3 at least 8 weeks after dose #2 and at least 4 months after dose #1_______________
Dose

_________________
Day Year

Dates unavailable-titer enclosed as proof of Immunity.

D. Meningitis Vaccine: Immunization required by Massachusetts State Law

1. One dose of MCV4-Tetravalent conjugate vaccine (Menactra or Menveo)..._____________ OR Mo Day Year 2. One dose of MPSV4-Tetravalent Polysaccharide vaccine (Menomune).............................................______________ Fall Admits-09/01/2007 Spring Admits-01/20/2008 Mo Day Year
* If a student elects NOT to have the required vaccination, the enclosed Massachusetts DPH Meningococcal Information and Waiver Form must be signed.

E. Varicella Vaccine: Proof of Immunity/Immunizations required by Massachusetts State Law

A history of chicken pox, a positive Varicella antibody, or two doses of varicella vaccine meets the requirement. 1. History of Disease yes no _________________ must include date of Disease
Mo Day Year

2. Varicella Antibody _____________ Result:

Mo Day Year

Reactive (Titer must be enclosed)

Non-Reactive

3. Immunization a. Dose #1-Immunized at 12 months after birth or later.............................................................._______________

Mo Day Year

b. Dose #2 at least one month after dose #1............................................................................._______________

Mo Day Year

Health Care Provider Signature or Stamp-REQUIRED

SIGNATURE ________________________________________________________________________________________________________________________

Due Date: July 1, 2012-Fall Entrants December 1, 2012-Spring Entrants

Immunization Record-Page 2
NAME_________________________________________________________________________________________________ Last First Middle Date of Birth

F. Polio: Completed primary series of polio immunization

Primary Series-Type of Vaccine: Last booster-Type of Vaccine: OPV OPV IPV IPV

yes

no
Mo Day Year

E-IPV.________________ E-IPV.________________
Mo Day Year

G. Human Papilloma Virus Recombinant Vaccine (HPV2, HPV4): Recommended

1. Dose #1 at elected date.._________________
Mo Mo Dose Mo Day Day Day Year Year Year

2. Dose #2 at least 8 weeks after dose #1..............._________________ 3. Dose #3 at least 6 months after dose #1 and at least 12 weeks after dose #2..________________

H. Hepatitis A-Recommended
1. Immunization (Hepatitis A): a. Dose #1 _______________
Mo Day Year

b. Dose #2 _______________
Mo Day Year

2. Immunization (combined Hepatitis A and B Vaccine): a. Dose #1 _______________ b. Dose #2 _______________

Mo Day Year Mo Day Year

c. Dose #3 ______________
Mo Day Year

I.

Pneumococcal Polysaccharide Vaccine: Recommended for high risk groups._____________

Mo Day Year

B II: Monovalent Measles, Mumps, Rubella: Proof of Immunity/Immunizations required by Massachusetts State Law
Measles (Rubeola): Monovalent 1. Dose #1-Immunized with live Measles at 12 months after birth or later..._________________
Mo Mo Day Day Year Year

2. Dose #2-Immunized any time 1 month after dose #1._________________ Titer enclosed as proof of immunity Rubella (German measles): Monovalent 1. Dose #1-Immunized with live Rubella at 12 months after birth or later.._________________
Mo Mo Day Day Year Year

2. Dose #2. ._________________ Titer enclosed as proof of immunity Mumps: (Monovalent) 1. Dose #1-Immunized with live Mump at 12 months after birth or later..._________________
Mo Mo Day Day Year Year

2. Dose #2._________________ Titer enclosed as proof of immunity Health Care Provider Signature or Stamp-REQUIRED
SIGNATURE ________________________________________________________________________________________________________________________