Before filling out this form please make sure that:

1. If you are an International Student, please be sure to have already taken the Tuberculosis test. If you have not taken it yet, please come back to this form once the test is completed and you have the results from your doctor.
2. Make sure that you have all of your shot records ready along with the dates.
First Name:*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Last Name:*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email address:*field type email
Hepatitis B - required by Oklahoma law
Date 1*field type date Date 2*field type date Date 3*field type date
row 1 Date 1*field type date
Birth-2 months
Date 2*field type date
1-4 months
Date 3*field type date
6-18 months
Add

	Date 1*field type date	Date 2*field type date	Date 3*field type date
row 1	Date 1*field type date Birth-2 months	Date 2*field type date 1-4 months	Date 3*field type date 6-18 months

DTaP - 5 doeses unless 4th dose is after age 4, OR for grades 6-12 3 doeses

	Date 1field type date	Date 2field type date	Date 3field type date	Date 4field type date
row 1	Date 1field type date 2 months	Date 2field type date 4 months	Date 3field type date 6 months	Date 4field type date 4-6 years

DPT/HIB - Diphtheria-Tetnus acellular-Pertussis / H. influenzae
Date 1field type date
row 1 Date 1field type date
15 months must be 4th dose of DTaP & HIB
Add
HIB - Haemophilus influenzae Type b3
Date 1field type date Date 2field type date Date 3field type date
row 1 Date 1field type date
2 months
Date 2field type date
4 months
Date 3field type date
6 months
Add

	Date 1field type date
row 1	Date 1field type date 15 months must be 4th dose of DTaP & HIB

	Date 1field type date	Date 2field type date	Date 3field type date
row 1	Date 1field type date 2 months	Date 2field type date 4 months	Date 3field type date 6 months

IVP - Inactivated Poliovirus vaccine

	Date 1field type date	Date 2field type date	Date 3field type date	Date 4field type date
row 1	Date 1field type date 2 months	Date 2field type date 4 months	Date 3field type date 15-18 months	Date 4field type date 4-6 years

MMR - Required by Oklahoma law (2 dose, 1st dose after age 1)
Date 1*field type date Date 2*field type date
row 1 Date 1*field type date
12-15 months
Date 2*field type date
4-6 years
Add
Varicella - Chickenpox
Date 1field type date
row 1 Date 1field type date
Must be at least 12 months of age
Add

	Date 1*field type date	Date 2*field type date
row 1	Date 1*field type date 12-15 months	Date 2*field type date 4-6 years

	Date 1field type date
row 1	Date 1field type date Must be at least 12 months of age

PCV-7 (Pneumococcal Conjugate vaccine) - highly recommended

	Date 1field type date	Date 2field type date	Date 3field type date	Date 4field type date
row 1	Date 1field type date 2 months	Date 2field type date 4 months	Date 3field type date 6 months	Date 4field type date 12-15 months

Hepatitis A
Date 1field type date Date 2field type date
row 1 Date 1field type date
Must be at least 2 years old. 6-8 months must pass between 1st & 2nd doses
Date 2field type date
Add

	Date 1field type date	Date 2field type date
row 1	Date 1field type date Must be at least 2 years old. 6-8 months must pass between 1st & 2nd doses	Date 2field type date

Meningitis

First year on-campus college students have increased risk of contracting meningococcal meningitis. The ACIP (Advisory Committee on Immunization Practices) recommends that college students be made aware of this disease and given the opportunity to become vaccinated.

OKWU Health Director requires that all student take Meningitis vaccine.

Please see this document for more information about the Meningitis vaccine: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.pdf

and the official site http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.html
Date taken/planning to take:field type date
Required - you can get it once you get to the University

TB Skin Test

TB Skin Test is REQUIRED for International Students

Date of test:field type date
Results:field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Today's Date:field type date
Date will be captured on form submission
Signature*field type signature

Immunization Records

Hepatitis B - required by Oklahoma law

DTaP - 5 doeses unless 4th dose is after age 4, OR for grades 6-12 3 doeses

DPT/HIB - Diphtheria-Tetnus acellular-Pertussis / H. influenzae

HIB - Haemophilus influenzae Type b3

IVP - Inactivated Poliovirus vaccine

MMR - Required by Oklahoma law (2 dose, 1st dose after age 1)

Varicella - Chickenpox

PCV-7 (Pneumococcal Conjugate vaccine) - highly recommended

Hepatitis A

Meningitis

TB Skin Test