Last Name First Name Date of Birth Student ID #

REQUIRED IMMUNIZATIONS
2018 – 2019
Massachusetts state law requires submission of the following immunizations or proof of immunity for
admission. Have your healthcare provider complete and sign this form, or attach immunization documents
from your provider, school or military sources in lieu of signature.

Action Item! – 2 STEPS:

1. Upload this form and all supporting documents (immunizations and titer records) using the UHS
patient portal.
2. Enter dates of vaccinations or titer results into fields in the patient portal. Go to: https://
umass.medicatconnect.com

Required Vaccines Dates Given MA State Requirements

MMR Two doses:

Measles, Mumps and Rubella, combined #1 12 /30 1989
/ #2 02/ 15 /1990
 Minimum of four weeks
-or- -or- between doses

Individual vaccines or positive titers #1 / / #2 / /  First dose given after first birthday
or Positive titer – date: / /
Measles -or-
#1 / / #2 / / Individual vaccines
Mumps or Positive titer – date: / /
-or-
#1 / / #2 / / Positive titers (blood tests for
Rubella or Positive titer – date: / / immunity)

Tdap Tdap: 08/ 20 /2018 One dose

Tetanus, Diphtheria, Pertussis

Meningococcal: MenACWY # 1 – date: / /  One dose at age 16 or older for

(meningitis vaccine) all incoming students age 21 or
 younger
Menactra® /Menveo®
#2 – date: / /  Second dose highly recommended
-or- -or- -or-
 Menomune® Signed waiver: Signed waiver. Go to the ‘forms’
tab on the patient portal.

Varicella (Chicken Pox) • First dose given after first birthday

#1 / / #2 / /
-or- • Minimum of four weeks between
-or- doses
Positive titer Positive titer – date: 08/ 17 /2018 -or-
-or- Positive titer (blood test for immunity)
-or-
History of disease: No Yes -or-
History of disease History of disease
If yes, date: / /
 Hepatitis B #1 / / #2 / /
Three doses
#3 / /
-or- Usual schedule at zero, one and four –
Hepatitis A and B combined -or- six months
Positive HBsAg titer – date:08/ 13 / 2018 -or-
-or- Positive titer (blood test for immunity)
Positive titer

HIGHLY RECOMMENDED IMMUNIZATIONS

ALERT: The UMass Amherst campus is considered to be in an outbreak status due to cases of
Meningococcal B – we strongly recommend all undergraduate students get vaccinated with either Bexsero
or Trumemba.

Meningococcal Group B
#1 / / #2 / / Two doses at least one month apart
 MenB-4C (Bexsero®)
-or- -or-
-or- #1 / / #2 / /
 MenB-FHbp (Trumenba®) Three doses at zero, two and six
#3 / / months

Second dose Meningococcal:

MenACWY
 First dose or waiver required;
Menactra® /Menveo®
Date: / / second dose highly
-or- recommended

 Menomune®

Human Papillomavirus (HPV) Three doses

#1 / / #2 / /
Usual schedule at zero, two and six
#3 / /
months

Td Date of most recent booster dose:

Tetanus and Diphtheria / /

Hepatitis A
#1 / / #2 / /

Other vaccinations:
Date: / /
 Influenza
 Pneumonia Date: / /
 Typhoid Date: / /
 Other: Date: / /

If there is a medical contraindication to any immunization, explain:

Dr. EHSAAN ROSHAN

Healthcare provider signature: Date: 08 / 26 /2018
Printed name Signature