(Revision – January 2016 - PG 1 of 2)

UNIVERSITY SYSTEM OF GEORGIA

REQUIRED
CERTIFICATE OF IMMUNIZATION
(Return this to the institution)

Return documentation to the college or university that you are applying to. Retain a copy of the completed form for your records.
STUDENT INFORMATION
Student ID: _________________ - __________________ - ______________________
Name: (Last)_____________________________(First)__________________________(Middle)____________________
Address: _________________________________________________________________________________________

City: _______________________________ State: ______________ Country: ________________ Zip Code: _________

Term/Year of Application: _____________ Age at time of application: _____ Date of Birth: _____/_____/__________

REQUIRED IMMUNIZATION INFORMATION (See the Immunization Requirements & Recommendations for USG Students documentation)
DATE OF POSITIVE
DATE DATE DATE HISTORY LAB/SEROLOGIC
VACCINE
MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY EVIDENCE

MMR1
/ / / /
1
Measles
/ / / / / /
1
Mumps
/ / / / / /
1
Rubella
/ / / / / /
3
Varicella (or history of Varicella)
/ / / / / /
Tetanus-Diphtheria
Pertussis (Whooping / / / /
4 4
Cough) Tdap Td Booster
Type Series:
Hepatitis B2 / / / / / / o 2 Dose Series / /
o 3 Dose Series
1—Not required if born before 1957. 2—Only required of students who are 18 years of age or younger at time of expected matriculation.
3—Required for all US born students born in 1980 or later; all foreign born students regardless of year born. 4 – Td booster only necessary if > 10 years since Tdap dose.

PERMANENT OR TEMPORARY IMMUNIZATION EXEMPTION

o This student is exempt from the above immunizations on the ground of permanent medical contraindication.
o This student is temporarily exempt from the above immunization until ______/______/____________.

CERTIFICATION OF HEALTH CARE PROVIDER (This information is required)

Name: _______________________________________________ Signature: _______________________________________________
Address: _____________________________________________________________________________________________________
Date of Issue: ________/________/__________ Telephone: ____________________________________________________________

EXEMPTIONS
Check the appropriate box, sign, and date if you are claiming exemption of the immunization requirement for one of the following reasons:
o I affirm that Immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in
the event of an outbreak of a disease for which immunization is required.

Student Signature: _____________________________________ Date: _____/_____/_______________

o I declare that I will be enrolling in ONLY courses offered by distance learning. I understand that if I register for a course that is offered on-campus or at a
campus-managed facility this exemption becomes void and I will be excluded from class until I provide proof of immunization.

Student Signature: _____________________________________ Date: _____/_____/_______________

 (Revision – January 2016 - PG 2 of 2)

UNIVERSITY SYSTEM OF GEORGIA

RECOMMENDED
CERTIFICATE OF IMMUNIZATION
(Return this to the institution)

Return documentation to the college or university that you are applying to. Retain a copy of the completed form for your records.
STUDENT INFORMATION
Student ID: _________________ - __________________ - ______________________
Name: (Last)_____________________________(First)__________________________(Middle)____________________
Address: _________________________________________________________________________________________
City: _______________________________ State: ______________ Country: ________________ Zip Code: _________
Term/Year of Application: _____________ Age at time of application: _____ Date of Birth: _____/_____/__________

RECOMMENDED IMMUNIZATION INFORMATION (See the Immunization Requirements & Recommendations for USG Students documentation)
DATE OF POSITIVE
DATE DATE DATE
VACCINE HISTORY LAB/SEROLOGIC
MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY
EVIDENCE
Human
Papillomavirus5 / / / / / /
Type Series:
Hepatitis A 6 / / / / / / o 2 Dose Series / /
o 3 Dose Series
7, 8 / /
Meningococcal ACWY / / 8
(MCV4) MCV4 Booster
Type Series:
Meningococcal B9 / / / / / / o 2 Dose Series
o 3 Dose Series

/ / / /
Annual Influenza6

5 – Strongly recommended for all unvaccinated males and females through age 26 years.
6 - Strongly recommended but not required.
7 – Strongly recommended if residing in campus housing, sorority housing, or fraternity housing.
8 – MCV4 Booster necessary if initial MCV4 dose was received more than 5 years prior to admittance.
9 - Consider if younger than 23 yrs of age.

CERTIFICATION OF HEALTH CARE PROVIDER (This information is required)

Name: _____________________________ Signature: _______________________________________________
Address: _______________________________________________________________________________________
Date of Issue: ______/______/__________ Telephone: ______________________________________________

Student Signature: _____________________________________ Date: _____/_____/_______________