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    Wittenberg University Immunization Record

    Patient's Name:
    Date of Birth
    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.


    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 1
    Dose 2
    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 MEASLES titer
    Positive MUMPS titer
    Positive MUMPS titer
    Positive Rubella titer
    Positive Rubella titer

    B. Meningococcal Quadrivalent vaccine  

    Dose 1
    Dose 1
    Dose 2
    Dose 2


    Strongly Recommended Immunizations:

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

    Dose 1
    Dose 1
    Dose 2
    Dose 2
    Booster Dose 3
    Booster Dose 3

    D Tetanus-Diphtheria-Pertussis

    1. Primary series D Tap or DTP
    1
    1
    2
    2
    3
    3
    2. TDAP Booster (not TD or DT) within the last 10 years:
    2. TDAP Booster (not TD or DT) within the last 10 years:

    E. Polio

    1. Primary series (minimum three dates required):
    1. Primary series (minimum three dates required):
    Dose 1
    Dose 1
    Dose 2
    Dose 2
    Dose 3
    Dose 3

    F. Hepatitis B immunization series

    Dose 1
    Dose 1
    Dose 2
    Dose 2
    Dose 3
    Dose 3

    G. History of Chickenpox or chickenpox vaccine

    1. Varicella vaccine
    1. Varicella vaccine
    or 2. Chickenpox illness
    or 2. Chickenpox illness

    H. Hepatitis A immunization series

    Dose 1
    Dose 1
    Dose 2
    Dose 2

    I. Human Papilloma Virus Vaccine

    Dose 1
    Dose 1
    Dose 2
    Dose 2
    Dose 3
    Dose 3
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