University Student Immunization Evidence Form

Student Information
Immunization Record
Vaccine Date Given - Dose 1 Date Given - Dose 2 Date Given - Dose 3 Healthcare Provider/Clinic
MMR (Measles, Mumps, Rubella)
Hepatitis B
DTP/DTaP/Tdap (Diphtheria, Tetanus, Pertussis)
Polio
Varicella (Chickenpox)
Meningococcal
Influenza
COVID-19
Other
Certification
Healthcare Provider Name
Signature
Date