Point Park University Non-Resident Student Immunization Form
Incoming students must complete the immunization requirements prior to arriving on campus. If you need assistance with getting immunizations, please contact your local health department or primary care physician. The Student Health Center does not provide immunizations. Please submit an official copy of your immunizations in addition or in place of filling out this form. FALL DEADLINE AUGUST 1ST, SPRING DEADLINE JANUARY 1ST
Upload an official copy of your immunizations.
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Full Name
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First Name
Middle Name
Last Name
Student ID Number
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What is your date of birth?
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ex: MM/DD/YYYY
Required Vaccines
Varicella (Chicken Pox)
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Please Select
Illness
Vaccine
Illness Date
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Dose 1 Date
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Dose 2 Date
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Measles, Mumps, Rubella (MMR)
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Measles, Mumps, Rubella Separate Vaccines
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Required for International Students
Polio - 4 dose series at ages 2, 4, 6-18 months, and 4-6 year
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Dates Received
Tuberculin Skin Test - within one year or chest x-ray documentation must be submitted
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Date planted
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Date Read
Recommended for All Students
Covid 19 Vaccine
Moderna
Pfizer
Johnson and Johnson
Dose 1 Date
Dose 2 Date
Additional Boosters
Hepatitis A - 2 doses
Dose 1 and 2 dates
Influenza
Last dose
Certification of Accuracy
By submitting this form, I certify that the immunization information provided is accurate and complete to the best of my knowledge. I understand that falsifying medical records or providing false information may result in disciplinary action in accordance with university policy.
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