---------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ------------------------------------------------------------------------ University Health Center University of Maryland College Park, MD 20742 Upload form to myuhc.umd.edu Immunization questions or information: 301-314-8114 Name (Last) First University ID# Date of Birth (mm/dd/yyyy) Cell phone number: Email Address: What is your home country? Parental/Guardian Consent (for students under age 18): until they turn 18. The Health Center will seek to notify parents in the event of an emergency. Signed Date **Allow one week for processing after your form has been submitted. **Once your form has been processed, you will receive a secure message by email. Submit this form with your provider's signature as supporting documentation . Step 3: Click on Forms (located on the left hand side of the page), then click on Immunizations (in the middle of the page) Relationship IMMUNIZATION RECORD Instructions for uploading immunizations: Step 1: Go to www.myuhc.umd.edu Step 2: Enter your directory ID and password to log on, then enter your UID (University ID) in the box and hit ENTER Step 4: Carefully enter your immunization dates in the appropriate fields Step 5 : Scroll down to the gray box and click "Add Immunization Record" to attach your supporting documentation If your provider does not sign this form, you must attach ONE of the following alternative forms of supporting documentation: 1. Vaccine record from your doctor/provider office that includes provider information 2. Up to date school or university immunization record 3. Provider signed proof of current or previous immunizations 4. Active duty (DD214) status in the US Military or International W.H.O Yellow Book showing MMR dates (completed by a medical provider) Please submit your immunization information ONLINE no later than the first day of class If you are in need of required vaccines, these are available at the University Health Center. Please call for an appointment when you arrive on campus. Many insurances can be billed for the cost of the vaccines. * Regarding the Mandatory Health Insurance Waiver : Submission of this form does not meet the Mandatory Health Insurance Waiver Requirement! Evidence of insurance must be provided yearly online at www.firststudent.com. *The University of Maryland requires that ALL students including credit/non-credit, degree/non-degree seeking, full-time/part-time, graduate/undergraduate, transfer and international students complete this form. **Student registration will be blocked if immunization information is missing. PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK. I give permission for such diagnostic and therapeutic procedures as may be deemed necessary for my student *You may save your entries and return to them later, but once you click Submit Final, you will not be able to make changes* Page 1 of 4 Updated 5.18 Last name__________________________ UNIVERSITY OF MARYLAND IMMUNIZATION RECORD University ID#_______________________ Vaccines 2 doses of MMR MMR −At least 4 weeks between doses − First dose given after 1st birthday − Second dose after age 4 Individual 2 doses of each individual Vaccines: component (2 measles, 2 mumps, − Measles 2 rubella) − Mumps −At least 4 weeks between doses − Rubella − First dose given after 1st birthday − Second dose after age 4 mm dd yyyy mm dd yyyy Positive Measles titer date _____/_____/_____ Result_________________________ Positive titers blood test mm dd yyyy *Lab report must be attached showing Mumps titer date _____/_____/_____ Result_________________________ immunity mm dd yyyy Rubella titer date _____/_____/_____ Result_________________________ mm dd yyyy Tdap _____/_____/_____ One dose given at age 11 or later mm dd yyyy Check one One dose given after age 16 Meningitis Menactra −May be waived by completing (meningo- Menveo Section C coccal vaccine) Unknown Check if waiver completed below in SECTION C Clinician name (MD/NP/PA) Clinician Signature Date SECTION B (REQUIRED): ALL UNDERGRADUATE STUDENTS MUST COMPLETE THIS SECTION _____/_____/_____ SECTION A (REQUIRED): ALL STUDENTS BORN AFTER 1956 MUST PROVIDE THIS INFORMATION Dose 2_____/_____/_____ mm dd yyyy mm dd yyyy Dates Given/Performed Dose 1_____/_____/_____ Dose 2_____/_____/_____ mm dd yyyy mm dd yyyy Dose 1_____/_____/_____ Mumps Requirements Dose 1_____/_____/_____ Dose 2_____/_____/_____ mm dd yyyy mm dd yyyy Rubella Measles Dose 1_____/_____/_____ Dose 2_____/_____/_____ mm dd yyyy YOUR DOCTOR/PROVIDER MUST SIGN HERE: Please review, sign, and stamp to verify immunization dates and information are correct. Clinician Phone Number OR OR OR OR AND Page 2 of 4 Updated 5.18