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  • James Madison University Immunization Form

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    Miguel Espiritu
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    1) The document is James Madison University's immunization form, which requires all new students to submit proof that they have received required vaccinations. 2) It instructs new students to download and print the form, have it completed and signed by a healthcare provider, and upload it along with their health insurance card to their student health portal by the listed due dates. 3) Failure to submit complete immunization documentation on time will result in an enrollment hold and $50 fine being placed on the student's account.

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    Immunization Form

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    1) The document is James Madison University's immunization form, which requires all new students to submit proof that they have received required vaccinations. 2) It instructs new students to download and print the form, have it completed and signed by a healthcare provider, and upload it along with their health insurance card to their student health portal by the listed due dates. 3) Failure to submit complete immunization documentation on time will result in an enrollment hold and $50 fine being placed on the student's account.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    157 views1 page

    James Madison University Immunization Form

    Uploaded by

    Miguel Espiritu
    1) The document is James Madison University's immunization form, which requires all new students to submit proof that they have received required vaccinations. 2) It instructs new students to download and print the form, have it completed and signed by a healthcare provider, and upload it along with their health insurance card to their student health portal by the listed due dates. 3) Failure to submit complete immunization documentation on time will result in an enrollment hold and $50 fine being placed on the student's account.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 1

    James Madison University Immunization Form

    COMMONWEALTH OF VIRGINIA LAW REQUIRES THAT THE CERTIFICATE OF IMMUNIZATION AND TB SCREENING BE COMPLETED AND
    SUBMITTED TO THE UNIVERSITY HEALTH CENTER.
    Instructions for new students:
    1) Download (if .pdf does not display correctly, open the file in Adobe Reader) and print the Immunization Form and have it completed
    and signed by a health care professional. An official immunization record from your doctor or another school will be accepted.
    2) Log into your MyJMUChart account to upload the completed and signed immunization form (or official record), as well as a copy of
    your health insurance card (front and back.) All uploaded forms must be in .pdf format. Immunizations must be up to date.
    3) Complete the required TB Assessment and Health History for NEW students located under the “forms” tab in MyJMUChart.
    Due dates for undergraduate students: July 8, 2020 for Fall 2020 semester start and December 13, 2020 for Spring 2021 start.
    Due date for graduate students: No later than the third Friday of the first semester attending JMU.
    An enrollment hold and a $50 fine will be placed on your account if your immunization form and TB Screening are not deemed complete
    by the Health Center staff.

    CERTIFICATE OF IMMUNIZATION*
    This MUST be signed by a health care provider
    Name (print): _______________________________________________ Date of Birth: ______/_______/_______________
    Date completed: _______/_______/_______ STUDENT ID NUMBER: __________________________

    REQUIRED IMMUNIZATIONS
    Tetanus, Diphtheria vaccine Date of most recent Tetanus containing vaccination (Must be within the past
    Has Tdap ever been given to this patient? Yes No 10 years) Date: (MM/DD/YY) ____/____/____
    Check one: Date: (MM/DD/YY) Date: (MM/DD/YY) Date: (MM/DD/YY)
    ___2-dose series
    Hepatitis B 1) ___/___/___ 2) ___/___/___ 3) ___/___/____
    ___3-dose series
    ___ Combined A+B
    Meningococcal Vaccine: Initial dose OR a booster dose must have Date: (MM/DD/YY) Date: (MM/DD/YY) If applicable, booster > 16 years old
    been received on or after their 16th birthday 1) ___/___/___ 2) ___/___/___ Date: (MM/DD/YY) ___/___/___
    Measles, Mumps, Rubella (MMR) Date: (MM/DD/YY) Date: (MM/DD/YY)
    Students born before 1957 are not required to have a second MMR 1) ___/___/___ 2) ___/___/___ OR Titer (Attach Copy)
    vaccination.
    Poliomyelitis (OPV) or (IPV) Date: (MM/DD/YY) ___/___/___
    TB Screening Student must complete questionnaire online at MyJMUChart

    RECOMMENDED BUT NOT REQUIRED


    HPV (Quadrivalent or Bivalent) Date: (MM/DD/YY) Date: (MM/DD/YY) Date: (MM/DD/YY)
    ☐ CERVARIX or GARDASIL ☐ GARDASIL9 1) ___/___/___ 2) ___/___/___ 3) ___/___/___
    Hepatitis A Date: (MM/DD/YY) Date: (MM/DD/YY)
    1) ___/___/___ 2) ___/___/___
    Meningococcal B Vaccine Date: (MM/DD/YY) Date: (MM/DD/YY) Date: (MM/DD/YY)
    (__MenB-4C OR ___ MenB-FHpb) 1) ___/___/___ 2) ___/___/___ 3) ___/___/___
    Varicella ☐ had disease Date: (MM/DD/YY) Date: (MM/DD/YY) OR Titer
    (two doses one month apart for adults with no history 1) ___/___/___ 2) ___/___/___
    of the disease)
    (Attach Copy)

    This form will not be accepted if not signed by a health care provider.
    HEALTH CARE PROVIDER SIGNATURE (Dr., Nurse, NP, PA, DO)
    Printed Name ______________________________________________________________ Phone _________________________

    Address _______________________________________________________________________________________________________

    Signature ______________________________________________________________________________ Date ____________________

    JMU Health Center Staff only Reviewed: __________________________ Reviewed by: _____________________________ Notified: ☐ Compliant ☐ Non-Compliant

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