NC State University Immunization Form
Name: ________________________________________________ Date of Birth: ______________________
(Last, First, Middle/Maiden) (MM/DD/YYYY)
Section A- Required for ALL Incoming Students- provide all dates in MM/DD/YYYY format
MMR (Measles, Mumps, Rubella) Varicella (Chickenpox) Diphtheria, Tetanus, Pertussis
Two (2) doses required on or Required if born after April 1, 2001, All students must submit documentation
AFTER first birthday/ 1 year approximate age/date of disease, or of three (3) DTP, Td, or Tdap vaccines
of age. positive serologic test. regardless of age. One MUST be a
Tdap (document in section below).
First Dose: ___________________ First Dose: ____________________
First Dose: ______________________
Second Dose: ________________ Second Dose: _________________
Second Dose: ___________________
OR OR
🔲 Serological testing- MUST
attach copy of results with
Age/date of disease:
Additional Dose: ___________________
Additional Dose: ___________________
numerical values and reference _____________________________
ranges. **Serological testing will Additional Dose: ___________________
NOT be accepted from labs
outside of the United States. OR
OR
🔲 Serological testing- MUST attach
copy of results. **Serological testing
Tdap booster
All students MUST show proof of a Tdap
🔲 Born before 1956 will NOT be accepted from labs
outside of the United States. booster after the age of 12.
Date given:
_________________________
Meningococcal Conjugate Vaccine (MenACWY) Polio
Three (3) doses required ONLY if 17
Required if born after January 1, 2003. One (1) dose given on or after the years of age or younger when classes
age of 16 required (2 doses preferred). begin. One dose must be after age 4.
First Dose:_______________________
Vaccine Name/ First Dose Date: __________________________________
Second Dose: ____________________
Third Dose: ______________________
Vaccine Name/ Second Dose Date: ________________________________
Additional Dose: ___________________
Hepatitis B Vaccine
Required if born after July 1, 1994. Either three (3) dose series or two (2) doses of HEPLISAV-B series. **Serological
testing is NOT accepted- must show proof of vaccine dates.
Three dose series Two dose series- HEPLISAV-B only (18 years+)
First Dose: __________________________ First Dose: _________________________
Second Dose: ________________________ Second Dose: ______________________
Third Dose: __________________________
________________________________________________________ ___________________
Signature and Credentials of Health Care Providers Date Page 1 of 4
NC State University Immunization Form
Name: ________________________________________________ Date of Birth: ______________________
(Last, First, Middle/Maiden) (MM/DD/YYYY)
Section B- Tuberculosis Screening- provide all dates in MM/DD/YYYY format
Tuberculosis Screening REQUIRED for ALL students- This is completed through the HealthyPack
Portal.
Tuberculosis testing is REQUIRED for students from countries with an increased incidence of
Tuberculosis (TB) See list of high risk countries on page 4 of this document.
Required to provide documentation of TB screening which was performed within the last year. Acceptable
tests include either an IGRA Blood Test (usually acceptable from home country; report must contain student
demographic information including full name and date of birth and results must be in English) or a TB skin test
performed in the United States.
Campus Health may recommend additional TB screening or work up after review of records submitted.
*** Please attach documentation of laboratory results or Tuberculin Skin Test (TST) placement and reading
documentation. ***
Section C- Recommended Immunizations (NOT REQUIRED) - provide all dates in MM/DD/YYYY format
Human Papillomavirus Hepatitis A Meningococcal B
(HPV) Document TwinRix (Hepatitis A/B)
vaccine in Hepatitis B section Vaccine Name: __________________
First Dose: ___________________
First Dose: ____________________ First Dose: ______________________
Second Dose: ________________
Second Dose: _________________ Second Dose: ___________________
Third Dose: __________________
COVID-19 Pneumococcal Conjugate (e.g. PCV13, PCV20, PPSV23)
Vaccine Name: ______________________
Manufacturer: __________________
First Dose: __________________________
Date: _________________________
Second Dose: _______________________
________________________________________________________ ______________________
Signature and Credentials of Health Care Providers Date
________________________________________________________ _______________________
Printed Name and Credentials of Health Care Providers Office Phone Number
_________________________________________________________ _______________________
Office Address City State Country Zip Code
Page 2 of 4
Guidelines For Completing The Immunization Record
Important: The immunization requirements must be met or according to NC law, you will be withdrawn from
classes.
Be certain that your Full Name (first and last) and Date of Birth appear on each sheet and that all forms are
mailed together. The records must have the vaccine administration dates. The dates MUST include the month,
day, and the year. Both pages MUST be signed.
Acceptable Records of your Immunizations may be obtained from any of the following:
● Personal Shot Records/Local Health Department – Must be verified by a doctor’s stamp or
signature, or by a clinic or health department stamp with address.
● Military Records or WHO (World Health Organization) Documents- These records may not contain
all of the required immunizations. Must have a clinic address.
● Previous College or University Records- Your immunization records do not transfer automatically.
You must request to have a copy sent to our Immunizations Department. Must have a clinic address.
Recommended Immunizations
Recommended Immunizations
North Carolina law requires individuals attending college or universities to receive certain vaccines. But in
order to be fully protected from vaccine‐preventable diseases, individuals should receive all immunizations
recommended by the Centers for Disease Control and Prevention (CDC). Vaccines to protect against the flu,
meningitis, HPV and others are available.
The following immunizations are recommended for college students, but not required:
● Meningococcal Disease
○ Meningococcal B
○ Meningococcal ACWY for anyone not required to receive vaccine (born after 1/1/2003)
● Hepatitis A
● Human Papillomavirus (HPV)
● Influenza
● COVID-19
The immunizations listed above can be obtained at a local physician’s office, health department, medical office,
urgent care center, or they are available by appointment at NC State Campus Health.
Page 3 of 4
High Burden TB Country List 2024
(Countries with TB incidence rates of ≥ 20/100,000 population)
Country Country Country Country
Afghanistan Djibouti Russian Federation
Lithuania
Algeria Dominican Republic
Madagascar Rwanda
Angola Ecuador Malawi
Sao Tome and Principe
Anguilla El Salvador Malaysia
Senegal
Argentina Equatorial Guinea Maldives Sierra Leone
Armenia Eritrea Mali Singapore
Azerbaijan Eswatini Marshall Islands Solomon Islands
Bangladesh Ethiopia Mauritania Somalia
Belarus Fiji Mexico South Africa
Belize French Polynesia Micronesia (Federated States South Sudan
of)
Benin Gabon Mongolia Sri Lanka
Bhutan Gambia Morocco Sudan
Bolivia Georgia Mozambique Suriname
Bosnia and Herzegovina Ghana Myanmar Tajikistan
Botswana Greenland Namibia Thailand
Brazil Guam Nauru Timor-Leste
Brunei Darussalam Guatemala Nepal Togo
Burkina Faso Guinea Nicaragua Tunisia
Burundi Guinea-Bissau Niger Turkmenistan
Cabo Verde Guyana Nigeria Tuvalu
Cambodia Haiti Niue Uganda
Cameroon Honduras Northern Mariana Islands Ukraine
Central African Republic India Pakistan United Republic of Tanzania
Chad Indonesia Palau Uruguay
China Iraq Panama Uzbekistan
China, Hong Kong SAR Kazakhstan Papua New Guinea Vanuatu
China, Macao SAR Kenya Paraguay Venezuela (Bolivarian Republic of)
Kiribati Peru Vietnam
Colombia
Kyrgyzstan Philippines Yemen
Comoros
Congo Lao People's Democratic Qatar Zambia
Republic
Côte d'Ivoire Republic of Korea Zimbabwe
Lesotho
Democratic People's Liberia
Republic of Moldova
Republic of Korea
Democratic Republic of the
Libya Romania
Congo
Data obtained from 2023 WHO Global Tuberculosis Report and reflects 2023 data
Persons from these countries should be screened for TB and TB infection. Persons from countries not found on this
list should only be tested if symptomatic or if they have risk factors.
Updated 03/11/2025 Page 4 of 4
