Pre-Matriculation/Registration Immunization Form

Name

UNI

cl;; COLUMBIA HEALTH

Pre-Matriculation/Registration Immunization Form

For Morningside & Manhattanville students only

This form must be completed by an MD/DO, NP, or PA who is not a relative. In addition to this completed and signed form, attach immunization records and copies of all laboratory reports (if required). You must submit all reports in English or they must be accompanied by a certified translation (at the student's expense); failure to do so will result in registration delays. All items are required as written below. Only this form will be accepted as proof of immunization.

Visit the Columbia Health website for additional information on pre-registration health requirements.

This section to be completed by the student:

Last Name UNI Email Address

First Name Date of Birth

Middle Initial School/Program

This section to be completed by a medical provider:

Measles (Rubeola), Mumps, Rubella (MMR): Two doses of MMR vaccine (after first birthday) OR two doses of

measles vaccine, one dose of mumps vaccine, and one dose of rubella vaccine OR positive titers (IgG) showing immunity to

measles, mumps, and rubella (with corresponding lab reports showing immunity values).

Option A MMR Immunizations

(On or after first birthday and at least 28 days apart)

Vaccine/Titer MMR Dose 1

MMR Dose 2

Date

Result

Documentation

Upload a Copy of Vaccination Record

Required

Option B Positive MMR IgG

Antibody titers

(lab reports required)

Measles (Rubeola) Titer Mumps Titer

Rubella Titer

Option C Measles, Mumps and Rubella Immunizations given separately

(On or after first birthday and at least 28 days apart)

Measles Dose 1 Measles Dose 2 Mumps Dose 1

DO NOT COMPLETE THIS SECTION IF OPTION A IS COMPLETE

Rubella Dose 1

Lab Report Required

Lab Report Required

Lab Report Required

Upload a Copy of Vaccination Record

Required

Updated: June 2022

New Student Immunization Form | 1

Name

UNI

COVID-19 Vaccine(s): Columbia University requires that all students must provide documentation of being fully

vaccinated (defined as completion of the initial vaccination and booster dose(s), if eligible) by a COVID-19 vaccine that is

authorized/approved by the US Food and Drug Administration or the World Health Organization.

Vaccine

Primary COVID-19 Dose 1

Primary COVID-19 Dose 2

(for 2-dose vaccines)

Booster Eligibility Booster Dose 1

In general, at least five months after the last dose of your initial 2-dose series or two months after an initial J & J vaccination.

Booster Dose 2

(if applicable)

Vaccine

Date

Documentation

Upload a Copy of Vaccination Card

Required

Influenza: Columbia University policy states that students receive or provide documentation they have received the

seasonal influenza vaccine between August 1 of the Fall term and May 1 of the Spring term.

Enter the date your most recent vaccine.

Only flu shots received on or after August 1 of the current academic year will meet University requirements. No-cost flu vaccines will be available in the fall and spring semesters.

Vaccine

Date

Result

Documentation

Upload a Copy of Vaccination Card

Required

Meningitis ACWY: Columbia University policy states that students must make an informed decision regarding this

vaccine. Submit your informed decision via the medical clearances section of the patient-portal (secure.health.columbia.edu).

Only those that select having received the vaccine must provide the vaccine details in this section.

If you indicate you have received this vaccine in the past 10 years (from the date of the form), the healthcare provider must enter the information below on the conjugate ACWY vaccine and be sure to include a copy of your immunization records showing this vaccine when you submit the form.

Enter the date of your most recent Meningitis ACWY vaccine if your online form selection was "I have been

vaccinated..."

Vaccine

Date

Result

Documentation

Upload a Copy of Vaccination Card

Required

I attest that all dates, results, and immunizations listed on this form are correct and accurate.

Medical Provider's Printed Name

Date

Medical Provider's Signature & Stamp

(Both required)

License Number

New Student Immunization Form | 2

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download