University of Richmond StudentHealthCenter
28Westhampton Way, Universityof Richmond,VA23173
(804-289-8064) wellness.richmond.edu
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Name:______URID:______Date of Birth:______
Virginia StateLawandtheUniversityofRichmondRequirethe FollowingImmunizations
1)MMR(Measles,Mumps,Rubella)Dose#1 (MM/DD/YYYY)/_/
Twodoseslivevaccinerequiredat orafter12monthsof age, atleastonemonthapartDose#2(MM/DD/YYYY)/_/
UseONLY If titers were drawn:
MeaslesTiter Date: (MM/DD/YYYY) ____/____/____ Result: Mumps Titer Date: (MM/DD/YYYY) ____/____/____ Result:______
Rubella Titer Date: (MM/DD/YYYY) ____/____/____ Result: ______
2)TETANUS/DIPHTHERIA/PERTUSSIS (Tdap): (MM/DD/YYYY) ____/____/____ (If vaccinedateisolder than10years, revaccinate.)
OR
TETANUS/DIPTHERIA(Td): (MM/YY/YYYY) ____/____/____(If vaccinedateisolder than10years. revaccinate)
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3)MENINGOCOCCALMCV VACCINE: (MM/DD/YYYY)____//(Vaccine date must beafter studentturned16.If not,revaccinate
OR orsignwaiver on web portal.)
MENINGOCOCCAL MPSV VACCINE: (mm/dd/yyyy) ____/____/____
4)HEPATITIS B VACCINE:(3 doses required orsign waiver on web portal) Dose#1: (MM/DD/YYYY) ___/____/____
Dose #2: (MM/DD/YYYY) ____/____/____
Dose #3: (MM/DD/YYYY) ____/____/____
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5) POLIO OPV VACCINE: (Last dose must be given after 4th birthday. If last dose given prior to 4th birthday, on web portal) LastDose Date: (MM/DD/YYYY) ____/____/____OR
POLIO IPV VACCINE: (Last dose must be given after 4th birthday. If last dose given prior to 4th birthday, sign waiver on we LastDose Date: (MM/DD/YYYY) ____/____/____
➠Verifiedby:HealthCareProvider’sSignature
NamePrinted
Address
Phone
Date
RECOMMENDEDIMMUNIZATIONS (NOT Required for Admission)
Name:______URID:______Date of Birth:______
A. VARICELLAVACCINE: Dose#1(MM/DD/YYYY):____/____/____ Dose #2(MM/DD/YYYY):____/____/____
OR Date of documented disease: Month____/Year____
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B. HEPATITIS A VACCINE (2doses vaccinegivenat 0,6-12months) Dose #1(MM/DD/YYYY):___/____/____Dose #2(MM/DD/YYYY):____/____/____
C. HUMANPAPILLOMAVIRUSVACCINE(HPV) 4 (3doses at 0, 2,and6monthintervals)
Dose #1:(MM/DD/YYYY)___/____/____Dose #2:(MM/DD/YYYY)____/____/____ Dose #3:(MM/DD/YYYY)___/____/___
D. HUMANPAPILLOMAVIRUSVACCINE(HPV)9 (3doses at 0, 2,and6monthintervals)
Dose #1:(MM/DD/YYYY)___/____/____Dose #2:(MM/DD/YYYY)____/____/____ Dose #3:(MM/DD/YYYY)___/____/___
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E. MENINGOCOCCAL B NOS VACCINE
Dose #1:(MM/DD/YYYY)___/____/____Dose #2:(MM/DD/YYYY)____/____/____ Dose #3:(MM/DD/YYYY)___/____/___
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F. PNEUMOCOCCALVACCINE PCV MM/DD/YYYY ____/____/____
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G .PNEUMOCOCCALVACCINE PPSV MM/DD/YYYY ____/____/____
Verifiedby:HealthCareProvider’sSignature
NamePrinted
Address
Phone
Date
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