Immunization Form

Student Health and Counseling Center

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043, FX:1-888-837-2146| www.uaf.edu/chc
Immunizations Required for Housing at UAF

Please use this form to submit immunization records if the Patient Portal is not working for you.

Per the Board of Regents' policy 09.11.010, all students living in high-density campus housing must provide immunizations.

Non-compliance will result in the cancellation of your housing assignment.

Immunization/Testing Requirements:
- Meningococcal (MCV4) (Last one administered after the age of 16. Required for those 16-20 years of age.)
- Tetanus (Tdap, Td) (Last one administered in the last 10 years.)
- 2 Mumps, Measles, Rubella (MMR)
- Tuberculosis Skin Test (TB) (Within the last 12 months and is required with initial move-in.)
Student name*

First NameLast Name
Student date of birth*

MonthDayYear
Date
Student UA Identification number?
Student's cell phone/ contact telephone number*
xxx-xxx-xxxx
Do we have permission to leave a voicemail using the phone number listed above?*

YesNo
Do we have permission to text message using the phone number provided above?*

YesNo
If yes, who is cell phone service provider (mobile carrier)?
GCI, AT&T, Verizon
Student email address*
example@example.com
Can we send a message from UAF SHCC to this email address?*

YesNo
Has the student received the Meningococcal (MCV4) immunization after the age of 16?*
Date of the Meningococal (MCV4) immunization after the age of 16.

MonthDayYear
Date
Has the student received the Tetanus immunization (Tdap, Td) within the last 10 years?*
Date of the student's most recent Tetanus immunization.

MonthDayYear
Date
Has the student received 2 Mumps, Measles, Rubella (MMR) immunizations?*

If the student received the MMR, please enter the dates MM/DD/YYYY of the student's 1st and 2nd immunization.

	Date of 1st Immunization	Date of 2nd Immunization
MMR

If the student received separate immunizations for Measles,Mumps, and Rubella, please enter the dates MM/DD/YYYY of the student's 1st and 2nd immunization.

	Date of 1st Immunization	Date of 2nd Immunization
Measles
Mumps
Rubella

Has the student completed a Tuberculosis Skin Test (TB) within the last 12 months?*
Please enter the date of the student last TB skin test.

MonthDayYear
Date
Required: Please upload immunization records confirming the date provided above. Please use the "Take Photo" options below if you need to submit pictures of the student's immunization records rather than uploading documents. Medical exemptions required documentation from a medical professional. Please have the student's medical provider complete UAF SHCC medical exemption form for any exemptions. It can be located under the "forms" tab on our website, https://www.uaf.edu/chc/

Browse Files

Cancelof
Take Photo of the student's immunization record confirming the data provided above.
Take an additional photo of the student's immunization record confirming the data provided above if needed.
Take an additional photo of the student's immunization record confirming the data provided above if needed.
Take an additional photo of the student's immunization record confirming the data provided above if needed.
Take an additional photo of the student's immunization record confirming the data provided above if needed.
I understand that if I am under the age 18, my legal guardian will need to sign this form.

By signing this form,

I hereby attest that I am submitting accurate information about my/the student's immunization status. I understand that UAF SHCC will share the status of my/the student's compliance with UA Board of Regents Immunization Policy with UAF Residence Life. For Alaskans, your signature indicates you are giving UAF SHCC permission to access your/the student's record in Alaska's Immunization Information System (VacTrak).
The information I have provided is accurate.
My/the student's compliance with UAF Board of Regents' Immunization will be shared with UAF Residence Life.
UAF SHCC has permission to access my/the student's VacTrak record.
Student or guardian signature if the student is under age 18.*

Clear
Student or Guardian Typed Name*
Date of Student or Guardian Signature

MonthDayYear
Date
Guardian contact phone number if student is under the age of 18.
xxx-xxx-xxxx
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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Student Health and Counseling Center