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Immunizations Page
Please see Immunize North Carolina site for more information.

EFFECTIVE SPRING 2010 GUIDELINES FOR COMPLETING IMMUNIZATION INFORMATION

Remember: Your immunization information is NOT considered COMPLETE until you have all of the following: Your Name, Date of Birth and NCSU ID# on all hardcopy pages submitted to us. Signatures/names of your doctor/nurse/clinic on shot records. Month/ Day /Year for MMR immunizations. At least Month/Year for all other immunizations. When applicable: Official copies of lab results verifiying immunity can be submitted in lieu of vaccination for the following: Measles, Mumps, Rubella (see more specific requirments below). Fax: 1.877.221.NCSU (6278) Mail: ATTN: Immunization Department Student Health Service NCSU Campus Box 7304 Raleigh, NC 27695 email: immunizations@ncsu.edu Once NCSU Student Health Immunization Department reviews your Forms, you will be 'cleared' or you will be contacted regarding missing information. This may take up to 4 weeks to complete. Please do not contact us about your immunizations or medical history until that time. You cannot be cleared by NCSU unless we have the following information: Completion of online immunization form. Paper copies verifiying immunization and/or serology dates that were submitted online. Medical History Form completed online.

PLEASE KEEP A COPY OF YOUR IMMUNIZATION RECORDS.

1: DTP, DTaP, Td (child or adult series): REQUIRED VACCINE Requirement is for at least three (3) doses of tetanus/diphtheria vaccine. ONE MUST HAVE BEEN WITHIN THE PAST 10 YEARS. Individuals enrolling in college for the first time on or after July 1, 2008, must meet the above requirement and if a booster dose is needed, should get Tdap (adult vacine) if available and not contraindicated. Please list booster doses under #2 or #3 below. Date for Dose 1:

Date for Dose 2:

Date for Dose 3:

Date for Dose 4:

Date for Dose 5:

2: Td Booster: List your most recent Td booster here if applicable. If you have gotten Tdap booster instead, please list that vaccine at #3 below. Date for Dose 1:

3: Tetanus, Diphtheria, and Pertussis (Tdap) Booster: Only use this section if you have received the new tetanus vaccine containing pertussis (Tdap); otherwise, use the section above (#2). Date for Dose 1:

4: Measles, Mumps, and Rubella (MMR): REQUIRED VACCINE Measles vaccination is NOT required if: 1. Diagnosis of disease prior to January 1, 1994 2. Documentation of serologic testing proving protective antibody titer against measles 3. Born prior to 1957 4. Enrolled in college or university for the first time before July 1, 1994 is not required to have a second dose of measle vaccine Mumps vaccination is NOT required if: 1. Documentation of serologic testing proving protective antibody titer against mumps 2. Born prior to 1957 3. Enrolled in college or university fo the first time before July 1, 1994 4. Individuals entering college prior to July 1, 2008 are not required to receive a second dose of mumps vaccine Rubella vaccination is NOT required if:

1. 50 years old or older 2. Enrolled in college for the ifrst time after your 30th birthday 3. Documentation of serological testing proving protective antibody titer Please specify the dates of your MMR immunizations. Date for Dose 1:

Date for Dose 2:

5: Measles Vaccine: Use this space to document individual measles vaccination when applicable. If you received the combined MMR, please document in #4 above. Date for Dose 1:

Date for Dose 2:

6: Measles Immunity: History of physician-diagnosed measles is acceptable. You MUST provide a written statement about having the disease from that physician. If needed, you MUST mail or fax verification of laboratory proof of measles immunity to NCSU Immunization Department. If applicable, please specify the date and result of any blood test for Measles immunity. Test Date:

Result: Positive 7: Rubella Vaccine: Use this space to document individual rubella vaccination. If you received the combined MMR, please use space above. Date for Dose 1: Negative

8: Rubella Immunity: Only laboratory proof of immunity to rubella is acceptable if the vaccine was not given. History of rubella disease, even with physician documentation, is not acceptable. You MUST mail or fax verification of laboratory proof of rubella immunity to NCSU immunization in addtition to noting it here.

Please specify the date and result of any blood test for Rubella immunity. Test Date:

Result: Positive 9: Mumps Vaccine: Use this space to document individual measles vaccination. If you received the combined MMR, please use space above. Please specify the dates of your Mumps immunizations. Two doses are required Date for Dose 1: Negative

Date for Dose 2:

10: Mumps Immunity: Only laboratory proof of immunity to mumps is acceptable if the vaccine was not given. History of mumps disease, even with physician documentation, is not acceptable. You MUST mail or fax verification of laboratory proof of mumps immunity to NCSU immunization in addtition to noting it here. Please specify the date and result of any blood test for Mumps immunity. Test Date:

Result: Positive Negative

11: Polio Vaccine: REQUIRED VACCINE for any student who will NOT be 18 years old when classes begin. Date for Dose 1:

Date for Dose 2:

Date for Dose 3:

Date for Dose 4:

Date for Dose 5:

12: Meningococcal Vaccine: Menactra Vaccine Only. RECOMMENDED, NOT REQUIRED Vaccination against meningococcal meningitis is recommended for undergraduate dormitory residents (especially freshmen). Date for Dose 1:

13: Meningococcal Vaccine: Menomune Vaccine Only. This vaccine may have been given instead of Menactra (above). If so, enter below: RECOMMENDED, NOT REQUIRED Vaccination against meningococcal meningitis is recommended for undergraduate dormitory residents (especially freshmen). Date for Dose 1:

14: Hepatitis B Vaccine: REQUIRED ONLY FOR STUDENTS BORN ON OR AFTER JULY 1, 1994. Hepatitis B vaccination is recommended for all students and strongly recommended for College of Veterinary Medicine students. Date for Dose 1:

Date for Dose 2:

Date for Dose 3:

15: Hepatitis B Immunity: If providing this information, please mail or fax verification of laboratory proof of hepatitis B immunity to NCSU immunization in addtition to noting it here. This is not a required test. If applicable, you may record your test results below. Test Date:

Result: Positive Negative

16: Hepatitis A Vaccine: RECOMMENDED Hepatitis A immunization is recommended for all students.

Date for Dose 1:

Date for Dose 2:

17: Hepatitis A/B Combination Vaccine: RECOMMENDED If you have had this vaccine instead of individual hepatitis A and B vaccines, you should note that here. Date for Dose 1:

Date for Dose 2:

Date for Dose 3:

18: Varicella (Chicken Pox) Vaccine: RECOMMENDED Varicella immunization or evidence of immunity is NOT required. If you received individual immunizations for Varicella, please indicate the dates that each dose was given. Date for Dose 1:

Date for Dose 2:

19: Haemophilus influenza type b (Hib) Vaccine: RECOMMENDED Hib vaccination is NOT required. If you have received this vaccine, please indicate the dates that each dose was given. Date for Dose 1:

Date for Dose 2:

Date for Dose 3:

Date for Dose 4:

20: Rabies Vaccine: HIGHLY RECOMMENDED for College of Veterinary Medicine students only.

Date for Dose 1:

Date for Dose 2:

Date for Dose 3:

21: Rabies Immunity: Please provide dates of your most recent titer if it has been greater than 2 years since your last rabies vaccine or booster. Test Date:

Result: Positive 22: Tuberculosis Screening International Students and/or Non-US Citizens: Are required to haveTubercuolosis screening within 12 months prior to the first day of class. We HIGHLY recommend students to wait and have screening done via NCSU Student Health Services 1 Date of Administration: Date Read: Negative

Result: Positive Negative mm Induration

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