Student Immunization Form

Student Immunization Form
Name*

First NameLast Name
Number*
900XXXXXX
Email*
example@grizzlies.adams.edu
The Colorado Department of Health requires that all students attending Colorado colleges/universities provide a copy of their immunization record to the school. It is required that all students provide the following immunization information:
- Verification of two (2) measles, mumps and rubella (MMR) vaccine
- Verification of Meningococcal vaccine (for those living in campus housing)
Certificate of Immunization for college/university students
Have you already submitted your Immunization records to Student Affairs?*

YesNo
Have you received 2 doses of the MMR Vaccine(Measles, Mumps, Rubella)?

YesNo
Date of First MMR Vaccine

MonthDayYear
Date
Date of Second MMR Vaccine

MonthDayYear
Date
You have indicated you have not received your MMR Vaccination please indicate below if you are requesting an exemption.

Exemption - MedicalExemption - Non-Medical
If you are requesting an Exemption for the MMR Vaccination please download the appropritate form at the follwoing link and upload the complted form below.

CDPHE Vaccine Exemption
Please upload a copy of your MMR Vaccine Verification or Exemption request: (links can be found above)*

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Have you received Meningococcal Vaccine?*

YesNo
Date of most recent Meningococcal Vaccine

MonthDayYear
Date
You have indicated you have not received your Meningococcal Vaccination please indicate below if you are requesting an exemption.

Exemption - Waiver
Meningococcal Disease Information and Vaccine Waiver (pg2)
Please upload a copies of your Meningococcal Vaccine Verification or Exemption request: (links can be found above)

Cancelof
In June of 2021, the ASU Board of Trustees adopted a policy requiring every student, faculty, and staff member to be vaccinated for COVID-19. While vaccination is still strongly encouraged, proof of vaccination is no longer mandatory. Uploading COVID-19 Vaccination records is now OPTIONAL.
Have you received your full or partial COVID 19 Vaccination or booster? OPTIONAL

YesNo
What type of vaccination or booster did your receive? (select all that apply)

Pfizer-BioNTech First dosePfizer-BioNTech Second doseModerna First doseModerna Second doseJohnson & Johnson/JanssenPfizer-BioNTech BoosterModerna Booster
Date of First/Single Dose

MonthDayYear
Date
Date of Second Dose

MonthDayYear
Date
Date of Booster Dose

MonthDayYear
Date
Upload a copy of your Vaccination Card here:

Cancelof
Should be Empty: