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Immunization Verification Form 2018
Immunization Verification Form 2018
Submission steps:
1. First create image files of your completed Immunization Verification Form and other related documents such as titer results. Here are some steps
that may help you do this:
• Take a picture of the completed PSU Immunization Verification Form with a camera or mobile device, making sure that the picture is legible.
Save the images to your computer if completing the process by computer. If completing on your mobile device you can use the images directly
from the device – please be sure to only upload images of the Immunization Verification Form and related documents as these images become a
permanent part of your medical record.
• Another option is to scan your Immunization Verification Form and related documents to your computer but you must be sure to save the file as
an image file such as jpg, jpeg, png, gif and make sure the file size is under 4MB.
2. Access the UHS website at http://studentaffairs.psu.edu/health-wellness
3. Click on MyUHS.
4. Click on I AM A PENN STATE STUDENT to agree to terms of use.
5. Log in using your PSU Student Access credentials (i.e. xyz12 and password).
6. Confirm your Date of Birth and click Proceed.
7. Click on Immunization Upload
8. Click on PSU Immunization Verification form and locate your image file. Continue this process until you have uploaded all pages of the Penn State
Immunization Verification Form and any related documents.
9. Click SAVE.
Communication with you regarding compliance/non-compliance will be done by secure message. Students will receive an email notification from Penn
State University Health Services that they received a secure message and to log into MyUHS to retrieve the message. Sometimes these emails may go
to your spam or junk email box, if so, edit your emails Spam Mail Options to allow messages from [email protected].
Example:
Should you encounter any technical issues with the online submission process please email [email protected] and include the student name and
PSUID# and a description of the technical issue you are experiencing.
Should you have any questions regarding the required Immunization Compliance process please visit our FAQ’s page -
https://studentaffairs.psu.edu/health-wellness/medical-services/immunizations/frequently-asked-questions or contact the Immunization Compliance Office
at 814-865-2398/[email protected].
Thank you,
The Pennsylvania State University
Immunization Compliance Office
Meningococcal B Men B Dose 1 Men B Dose 2 Men B Dose 3 Please specify vaccine type such as Trumenba
(Serogroup B) or Bexsero
____ /____ /______ ____ /____ /______ ____ /____ /______
MM DD YYYY MM DD YYYY MM DD YYYY _______________________________
Tdap Tdap - Last dose Please specify vaccine type such Td Td - Last dose
(tetanus, diphtheria, and pertussis) as Boostrix or Adacel (tetanus, diphtheria)
[this is not the same as DTap] ____ /____ /______ ____ /____ /______
MM DD YYYY ________________________ MM DD YYYY
Varicella Vaccine Varicella Dose 1 Varicella Dose 2 Varicella Titer
OR Varicella Blood Titer Test *Attached copy of lab results required
(equivocal or negative results are NOT accepted) ____ /____ /______ ____ /____ /______
MM DD YYYY MM DD YYYY OR ____ /____ /______
MM DD YYYY
* = REQUIRED
* Date: * Healthcare Provider Name (please print): * Signature and Title: * Phone Number & Address:
STUDENT:
Upload the completed Immunization Verification Form and all other related documents through the University
Health Services MyUHS portal – http://studentaffairs.psu.edu/health-wellness/medical-services/myuhs