Last Name ____________________ First Name ________________ Middle Initial _____
Social Security Number _________
Street Address ______________________________________________________
City __________________________ State ______________ Zip _________________
Date of Birth _______________ Semester/Year of Enrollment __________________________

Part B ... to be completed and signed by a health care provider. Dates must include month and year.

Required Immunization:
1. For students born before 1957, Rubella immunity, as in IV.
2. For all students, either
a) MMR immunity, as in I; OR
b) measles, mumps and rubella immunity, as in II, III, and IV.

I.	MMR (Measles, Mumps, Rubella) - Note: Date must be after 1970.
	1. Dose 1 - immunized at 12 months of age or later, AND	(MO/DAY/YR)___/___/___
	2. Dose 2 - immunized at least 30 days after Dose 1	(MO/DAY/YR)___/___/___
II.	MEASLES - Note: Date must be after March 4, 1963, but not before first birthday.
	1. Had disease; confirmed by physician diagnosis in office record, OR	(MO/YR)___/___
	2. Born before 1957 and therefore considered immune, OR	(MO/YR)___/___
	3. Has laboratory evidence of immune titer (specify date of titer), OR	(MO/YR)___/___
	4. Immunized with live measles vaccine at 12 months of age or later, OR	(MO/DAY/YR)___/___/___
	5. Immunized with 2nd dose of live measles vaccine at least 30 days after 1st dose.	(MO/DAY/YR)___/___/___
III.	MUMPS - Note: Date must be after April 22, 1971
	1. Had disease; confirmed by physician diagnosis in office record, OR	(MO/YR)___/___
	2. Born before 1957 and therefore considered immune, OR	(MO/YR)___/___
	3. Has laboratory evidence of immune titer (specify date of titer), OR	(MO/YR)___/___
	4. Immunized with live vaccine at 12 months of age or later, OR	(MO/DAY/YR)___/___/___
IV.	RUBELLA - Note: Date must be after June 9, 1969
	1. Has laboratory evidence of immune titer (specify date of titer), OR	(MO/YR)___/___
	2. Immunized with live vaccine at 12 months of age or later, OR	(MO/DAY/YR)___/___/___
	Exemption of grounds of permanent medical contraindication
	Exemption of grounds of temporary medical contraindication
	a) pregnancy ... expected date of confinement	(MO/YR)___/___
	b) other ... anticipated date of end of confinement	(MO/YR)___/___

Immunization status indicated above is certified by
Signature of physician or health facility official ____________________________________
date __________
Name and address of physician or public health facility
_______________________________________________________________________

Religious Exemption (student signature required only for religious exemption) I affirm that immunization as required by the University System of Georgia is in conflict with my religious beliefs. I understand that I am subject to exclusion in the event of an outbreak of a disease for which immunization is required. signature of student ___________________________________ date ______________ NOTE: Students are advised to keep a photocopy of this form for future use.