ARIZONA STATE UNIVERSITY IMMUNIZATION REQUIREMENT

Arizona State University policy SSM 106-01 requires the following from ALL incoming and transfer students:
Proof of TWO MMR Measles, Mumps and Rubella vaccinations. The first vaccination is given at or after 1 year of age and the
second is commonly given at or after 4-6 years of age. If your records do not reflect this immunization schedule, the two MMR
vaccinations must be at least 28 days apart from each administrated date. Note: The first MMR must be at or after 1 year of
age.
OR
Proof of a POSITIVE titer test that shows immunity to RUBEOLA (Measles).
At least one MMR vaccination must have been given after 1979.
All documents must be in English (translated copies will be accepted).
Students born before January 1, 1957 are not subject to this requirement.

Please submit your documents in person or in one of the following ways:

MAIL: FAX: EMAIL:
Immunizations Department 480-965-8914
ASU Health Services immunizations@asu.edu
Arizona State University PHONE:
P.O. Box 872104 480-965-8177
Tempe, AZ 85287-2104

NAME: LAST: ____________________________________ FIRST:______________________________________ M.I______________

ASU ID:_____________________________ ASU EMAIL:_______________________________ DATE OF BIRTH:__________________

(10-digits) (MM/DD/YY)
REQUIRED IMMUNIZATIONS: Month: Day: Year:
MMR #1: Measles, Mumps, Rubella (after 1st birthday)
MMR #2: Measles, Mumps, Rubella (given at least 28 days or more after the first)
OR
Copy of blood test results proving immunity to the RUBEOLA (Measles) must be
attached
OPTIONAL RECOMMENDED IMMUNIZATIONS:
Tetanus, Diphtheria (TD) or Tetanus, Diphtheria, Pertussis (Tdap)- Most Recent
Meningococcal ACWY (Menactra, MCV4, Menveo) - Most Recent
Meningococcal B (Bexsero) #1
Meningococcal B (Bexsero) #2 (at least 1 month apart from the first)
OR
Meningococcal B (Trumenba) #1
Meningococcal B (Trumenba) #2 (second dose 2 Months after the first)
Meningococcal B (Trumenba) #3 (6 months after the first)

Healthcare Provider Office Stamp: ___________________________________ Date ___________

(If no stamp, you MUST send copy of records)
*Provider Stamp is not necessary if a copy of vaccination records are attached.

2016