| AMERICAN
UNIVERSITY
WASHINGTON,
DC |
|
|
IMMUNIZATION
FORM |
| Upon
completion, fax this form without
a cover sheet to 202-885-8350 |
Student: District of Columbia law requires
that all students under age 26, enrolled in schools within the district,
provide proof of having had the following immunizations: Two vaccinations
against Measles, Mumps, and Rubella, given after 1 year of age and
at least 30 days apart. One Diphtheria/Tetanus booster given within
the past ten years. Two doses of Varicella (Chicken Pox) vaccine 60
days apart. And a series of three Hepatitis B immunizations administered
over a 6 month period. This form should be completed with your physician
present so s/he can consolidate your records and update any immunizations
you may be missing. If you submit an immunization form that is incomplete,
has invalid dates, or lacks a validating stamp it will not be processed
and will delay your registration for classes.
|
Doctor: Vaccine preventable diseases
occur on college campuses where students are not immunized or inadequately
immunized. You help us to protect AU students and their contacts by
not accepting anecdotal information, and by submitting immunization
data from your office records or from records presented for your review
which include complete dates (month/day/year) of administration. Where
records are missing or incomplete please update immunizations to ensure
that the student is protected, and enables him/her to complete requirements
for matriculation at American University. If a claim to immunity is
made based on your patient having the disease, documentation from
the original treatment record is required, or the result/s from an
antibody titer including test performed, result, and reference range
must be returned with this form.
|
| (Please
print clearly) Last name, First name
|
AU (7 digit)
ID # |
m/d/y
of Birth |
| AU School
or Program (CAS, Washington Semester, Law, ect.) |
Expected year
of program completion |
Fax number to
reach you |
| 2. HEPATITIS
B |
Dose 1 - Immunized |
Date |
| |
Dose 2 - Immunized at least 30 days after Dose
1 |
Date |
| |
Dose 3 - Immunizaed at least 6 months after
Dose 2 |
Date |
| 3. TETANUS/DIPHTHERIA
|
|
Student must have
completed the primary series and received 1 adult Tetanus/diphtheria
booster within the past ten years
|
Date |
| 4. MMR
(Measles, Mumps, Rubella given as a single injection) |
| |
Dose 1 - Immunized after first
birthday
|
Date |
| |
Dose 2 - Immunized at least 30 days after Dose
1 |
Date |
Complete this section
only if you have individual immunizations for M,M,R.
| MEASLES |
Dose 1 - Immunized after first
birthday
|
Date |
| |
Dose 2 - Immunized at least 30 days after Dose
1 |
Date |
| MUMPS |
Dose 1 - Immunized after first
birthday
|
Date |
| |
Dose 2 - Immunized at least 30 days after Dose
1 |
Date |
| RUBELLA |
Dose 1 - Immunized after first
birthday
|
Date |
| |
Dose 2 - Immunized at least 30 days after Dose
1 |
Date |
| ___________________________________________ |
________________________________________________________ |
| Practitioner
Name / Title (MD., RN., P.A.) |
Practitioner
Signature |
__________________________ |
|
| Date this form
was completed |
An office stamp
must be used to validate this form |
|
|
|
