Georgetown University Immunization History Form
Georgetown University Student Health Center ▪ Darnall Hall, Ground Floor
3800 Reservoir Road, NW, Washington, DC 20007▪ Phone (202) 687-2200 ▪ Fax (by request)
PART I: TO BE COMPLETED BY STUDENT
GOCard (9-digit number): Entry Semester (Fall/Spring/Summer & Year):
Last Name: First Name:
Date of Birth (MM/DD/YYYY): Current Age:
Phone Number: Email Address:
D.C. Law 3-20 requires students to provide documentation of vaccination or laboratory evidence of immunity (if
appropriate) from Diphtheria, Tetanus, Hepatitis B, Measles, Mumps, Rubella, Varicella and Meningitis. Students under 18
years must also be vaccinated against Polio.
Please submit this form through the Immunization Portal: [Link]
PART II: REQUIRED IMMUNIZATIONS TO BE COMPLETED BY HEALTH CARE PROVIDER
For inputting all dates, please use the format: MM/DD/YYYY
Initial Series Dose #1 Dose #2 Dose #3
Injection Name:
________________
Hepatitis B
Additional Series Dose #1 Dose #2 Dose #3
Injection Name:
_________________
OR Immunity Titers Test Result Date: Immunity Result:
Must Include Lab Report for □ Immune
Confirmation □ Not Immune
Option 1:
MMR Dose #1 MMR Dose #2
Or Option 2:
Measles Dose #1 Measles Dose #2
OR Measles Immunity Titers Test Result Date: Immunity Result:
Must Include Lab Report for □ Immune
MMR
Confirmation □ Not Immune
Mumps Dose #1 Mumps Dose #2
OR Mumps Immunity Titers Test Result Date: Immunity Result:
Must Include Lab Report for □ Immune
Confirmation □ Not Immune
Rubella Dose #1 Rubella Dose #2
OR Rubella Immunity Titers Test Result Date: Immunity Result:
Must Include Lab Report for □ Immune
Confirmation □ Not Immune
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Georgetown University Immunization History Form Continued
Dose #1 Dose #2
Varicella
OR History of Disease: Date of Disease (MM/YYYY):
□ Yes
□ No
OR Immunity Titers Test Result Date: Immunity Result:
Must Include Lab Report for □ Immune
Confirmation □ Not Immune
Latest Dose
Td or
Tdap
Injection Name: Dose #1 Dose #2
(ACWY)
_________________
Men
OR Opting for Waiver: Date Waiver Uploaded Online:
□ Yes
□ No
Type Dose #1 Dose #2
□ IPV
□ OPV
Polio
Dose #3 Dose #4 Dose #5
Signature of Health Care Provider (REQUIRED): Office Stamp:
Printed Name with Credentials (MD, DO, NP, RN, etc):
Office Address:
Office Phone: Date:
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Georgetown University Immunization History Form
Georgetown University Student Health Center ▪ Darnall Hall, Ground Floor
3800 Reservoir Road, NW, Washington, DC 20007▪ Phone (202) 687-2200 ▪ Fax (by request)
PART I: TO BE COMPLETED BY STUDENT **OPTIONAL FORM**
GOCard (9-digit number): Entry Semester (Fall/Spring/Summer & Year):
Last Name: First Name:
Date of Birth (MM/DD/YYYY): Current Age:
Phone Number: Email Address:
D.C. Law 3-20 requires students to provide documentation of vaccination or laboratory evidence of immunity (if
appropriate) from Diphtheria, Tetanus, Hepatitis B, Measles, Mumps, Rubella, Varicella and Meningitis. Students under 18
years must also be vaccinated against Polio.
Please submit this form through the Immunization Portal: [Link]
ADDITIONAL IMMUNIZATIONS—Not Required by Georgetown University
Initial Series Dose #1 Dose #2 Dose #3
Injection Name:
_________________
Covid
Boosters Dose #1 Dose #2 Dose #3
Injection Name:
_________________
Dose #1 Dose #2 Dose #3
HPV
Injection Name: Dose #1 Dose #2 Dose #3
Men
(B)
_________________
Dose #1 Dose #2
Hepatitis
A
Or Immunity Titers Test Result Date: Immunity Result:
Must Include Lab Report for □ Immune
Confirmation □ Not Immune
Signature of Health Care Provider (REQUIRED): Office Stamp:
Printed Name with Credentials (MD, DO, NP, RN, etc):
Office Address:
Office Phone: Date:
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Georgetown University Immunization Dosing Guide
Georgetown University Student Health Center ▪ Darnall Hall, Ground Floor
3800 Reservoir Road, NW, Washington, DC 20007▪ Phone (202) 687-2200 ▪ Fax (by request)
Required immunizations for students under the age of 26
*There are no vaccine requirements for students over the age of 26 – please fill out your TB screening
questionnaire
• 3 doses of Engerix-B, Recombivax, or Twinrix* to complete the immunization series
o Dose scheduling: There must be at least 4 weeks between doses #1 and #2, at least 8 weeks
between doses #2 and #3, and at least 16 weeks between doses #1 and #3
o *There is an alternative schedule for Twinrix—please reach out to the Student Health Center for
Hepatitis B
more information as needed.
OR
• 2 doses of Heplisav-B for those 18 years of age and older to complete the immunization
series
o Dose scheduling: Dose #2 should be 4 weeks after the dose #1
OR
• An uploaded lab report showing positive immunity
o Please note: if immunity results low or non-immune, further vaccination(s) will be needed
• 2 doses of MMR are required to complete the immunization series
o Dose scheduling: dose #1 must be given after 12 months of age; dose #2 should be 4 weeks after
the dose #1
OR
• 2 doses of Measles, 2 doses of Mumps, and 2 doses of Rubella to complete the immunization
MMR
series
o Dose scheduling: dose #1 must be given after 12 months of age; dose #2 should be 4 weeks after
the dose #1
OR
• An uploaded lab report showing positive immunity
o Please note: if immunity results low or non-immune, further vaccination(s) will be needed
• 2 doses are required to complete the immunization series
o Dose scheduling: dose #1 must be given after 12 months of age; dose #2 should be 4 weeks after
the dose #1
Varicella
OR
• An uploaded lab report showing positive immunity
o Please note: if immunity results low or non-immune, further vaccination(s) will be needed
OR
• History of disease attestation by a medical professional
o Must list MONTH/YEAR of disease incidence with the signature from a healthcare provider
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• Most recent Tetanus/Diphtheria (TD) or Tetanus/Diphtheria/Pertussis (Tdap) dose must be within the
last 10 years per DC law
o Please note: if you live in a location where Tdap or Td vaccination is not available, please plan to
TD/TDAP
complete this vaccination as soon as possible once it is accessible to you or at the Student Health
Center
▪ If you plan to make an appointment at Student Health Center (SHC) for this, we recommend that
you please complete and upload the MedStar Health Registration form. This form allows our
office to register you as a patient for future visits at SHC.
Required immunizations for students under the age of 26 living in
Georgetown University housing
•
Men (ACWY)
Meningococcus (ACWY) - Menactra, Menveo, and MenQuadfi
o Most recent dose must be on or after 16 years of age
OR
• A signed and uploaded Meningitis waiver/fact sheet
Required immunizations for students under the age of 18
• OPV/IPV 3 or 4 doses per ACIP requirements
Polio
Optional immunizations
• COVID-19
• HPV
• Hepatitis A
• Meningitis B (Bexsero and Trumenba)
Please ask your healthcare provider or the Student Health Center for dosing requirements.
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