Wittenberg University Immunization Record

Patient's Name:

Last

First

Middle

Date of Birth

Required of All Students

The information you provide on the form is strictly for the use of the Health Center (operated by Mercy Health) and the Sport Medicine Department and will not be released to anyone without your knowledge and consent. All full-time students must complete this form. Student-athletes at Wittenberg will have an additional health form that must be completed and submitted to the Athletic Department.

Tips on getting copies of immunization records:

1. Check with your parents or family members for records of childhood immunizations.

2. Contact your family physician or pediatrician.

3. Contact the clinic or hospital where shots were given.

4. Check your passport of other travel health records for overseas trips.

5. Call your elementary, middle, or high school for copies of immunization records.

Please select here if you have immunization exemption paperwork. If yes, please submit the immunization exemption paperwork to deanofstudents@wittenberg.edu with an explanation of your qualifications for exemption.

Yes

Required Immunizations:

A. MMR (Measles, Mumps, Rubella) Two live immunizations required on or after the first birthday, at least 30 days apart.

Dose 1

Dose 2

A positive serological test for immunity to any of the above diseases is acceptable instead of immunizations. A history of the disease is not acceptable.

Positive MEASLES titer

Positive MUMPS titer

Positive Rubella titer

B. Meningococcal Quadrivalent vaccine

Dose 1

Dose 2

Strongly Recommended Immunizations:

C. COVID-19 Vaccine: Product Name (Moderna, Pfizer, or Johnson & Johnson)

Dose 1

Dose 2

Booster Dose 3

D Tetanus-Diphtheria-Pertussis

1. Primary series D Tap or DTP

2. TDAP Booster (not TD or DT) within the last 10 years:

E. Polio

1. Primary series (minimum three dates required):

OPV (oral)

IPV (injected)

Dose 1

Dose 2

Dose 3

F. Hepatitis B immunization series

Dose 1

Dose 2

Dose 3

G. History of Chickenpox or chickenpox vaccine

1. Varicella vaccine

or 2. Chickenpox illness

H. Hepatitis A immunization series

Dose 1

Dose 2

I. Human Papilloma Virus Vaccine

Dose 1

Dose 2

Dose 3