James Madison University Immunization Form
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
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 _______________________________________________________________________________________________________
JMU Health Center Staff only Reviewed: __________________________ Reviewed by: _____________________________ Notified: ☐ Compliant ☐ Non-Compliant