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Required Student Immunization Form, Study notes of Public Health

Stanford UniversityPublic Health

Dear Student,. Welcome to the University of South Carolina Union Campus! We are glad you have chosen us to meet your higher education goals. Please complete ...

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2022/2023

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Required Student Immunization Form
Dear Student,
Welcome to the University of South Carolina Union Campus! We are glad you have chosen us to meet your higher education goals.
Please complete and return the attached immunization form. USC Union requires a complete immunization record for all students.
Complete the following immunization form and return it by mail or fax to the Student Affairs Office as soon as possible. Be certain to
include your full name, date of birth, and Social Security number.
USC Union
Student Affairs Office
PO Drawer 729
Union, SC 29379
Fax: (864) 424-8092
Guidelines for Completing Immunization Records
According to University policy, the immunization requirements must be met and on file at USC Union before you register for classes.
In order to avoid excessive waiting times, please have all of your immunization requirements completed and the form sent to USC Union
prior to your orientation date.
Acceptable records of your Immunizations
Be certain that your name, date of birth, and ID number (Social Security) appear on each sheet and that all forms are mailed together.
The records must be in black ink and the dates of vaccine administration must include the month, day, and year. All records
must be in English. Please keep a copy for your own personal records.
* High School records. These may contain some, but not all of your immunization information. Contact USC Union for help
if needed. Your immunization records do not transfer automatically. You must request a copy from your high school.
* Personal shot records. These records must be verified by a doctor’s stamp or signature or by a clinic/health department
stamp.
* Local health department.
* Military Records or World Health Organization (WHO) documents.
* Previous College or university. Your immunization records do not transfer automatically. You must request a copy from
your school.
SECTION A – Required Immunizations
Have your physician or health department clinician fill in your immunization record and update any needed
immunizations that are required in Section A. This form must be signed by an MD, PA, PA-C, FNP, FNP-C, or stamped
by the health department.
SECTION B – Recommended Immunizations from the Centers for Disease Control and Prevention (CDC). Certain
academic departments and programs may require some of these recommended immunizations so you may want to consult
with your academic department for specific immunization requirements. USC Union recommends receiving the Hepatitis
B series. You may elect to receive these immunizations from your private physician or health department prior to arriving
at the University. Please refer to the note on the next page regarding CDC recommendations for Hepatitis B and
Meningitis.
SECTION C – Parental Consent
If you are under the age of 18, you will need a signature from a parent or legal guardian authorizing any medical
treatment sought at the University.
SECTION D – Immunization Exemptions
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Required Student Immunization Form

Dear Student,

Welcome to the University of South Carolina Union Campus! We are glad you have chosen us to meet your higher education goals.

Please complete and return the attached immunization form. USC Union requires a complete immunization record for all students.

Complete the following immunization form and return it by mail or fax to the Student Affairs Office as soon as possible. Be certain to

include your full name, date of birth, and Social Security number.

USC Union

Student Affairs Office

PO Drawer 729

Union, SC 29379

Fax: (864) 424-

Guidelines for Completing Immunization Records

According to University policy, the immunization requirements must be met and on file at USC Union before you register for classes.

In order to avoid excessive waiting times, please have all of your immunization requirements completed and the form sent to USC Union

prior to your orientation date.

Acceptable records of your Immunizations

Be certain that your name, date of birth, and ID number (Social Security) appear on each sheet and that all forms are mailed together.

The records must be in black ink and the dates of vaccine administration must include the month, day, and year. All records

must be in English. Please keep a copy for your own personal records.

* High School records. These may contain some, but not all of your immunization information. Contact USC Union for help

if needed. Your immunization records do not transfer automatically. You must request a copy from your high school.

* Personal shot records. These records must be verified by a doctor’s stamp or signature or by a clinic/health department

stamp.

* Local health department.

* Military Records or World Health Organization (WHO) documents.

* Previous College or university. Your immunization records do not transfer automatically. You must request a copy from

your school.

SECTION A – Required Immunizations

Have your physician or health department clinician fill in your immunization record and update any needed

immunizations that are required in Section A. This form must be signed by an MD, PA, PA-C, FNP, FNP-C, or stamped

by the health department.

SECTION B – Recommended Immunizations from the Centers for Disease Control and Prevention (CDC). Certain

academic departments and programs may require some of these recommended immunizations so you may want to consult

with your academic department for specific immunization requirements. USC Union recommends receiving the Hepatitis

B series. You may elect to receive these immunizations from your private physician or health department prior to arriving

at the University. Please refer to the note on the next page regarding CDC recommendations for Hepatitis B and

Meningitis.

SECTION C – Parental Consent

If you are under the age of 18, you will need a signature from a parent or legal guardian authorizing any medical

treatment sought at the University.

SECTION D – Immunization Exemptions

Recommended Immunizations for the College Population

The Centers for Disease Control and Prevention recommends that college students be educated about the benefits

of vaccination against meningitis (a potentially fatal bacterial infection) and hepatitis B. The recommendation is

based on recent studies showing that college students, particularly freshman in residence halls, have a six-fold

increased risk for meningitis and an increased risk for hepatitis B. In addition, the State of South Carolina requires

higher education institutions to inform students and parents about the risk of contracting these diseases and the

availability of preventive vaccines. The University of South Carolina encourages all students, parents and

guardians to learn more about these serious communicable diseases and to make an informed decision regarding

protection.

The University now requires all incoming students age 24 or less to be immunized against Meningococcal

disease. The meningococcal vaccination is available at the Thomson Student Health Center’s Immunization

clinic. Meningococcal disease is rare but a potentially fatal bacterial infection. Less than 3,000 cases annually

in the United States are recorded, with approximately 125 cases on college campuses. When meningitis strikes,

its flu-like symptoms make it difficult to diagnose. Transmission of the disease occurs from person to person

through respiratory or oral secretions. Cases of meningitis among teens and young adults aged 15 to 24 years old

have more than doubled since 1991. CDC does not consider that this risk warrants any changes in university

living arrangements. The University of South Carolina and the American College Health Association highly

recommends that students be educated and consider being vaccinated against the disease.

Hepatitis B virus exposure can result in a serious disease that attacks the liver. There is no cure for this disease.

CDC estimates that approximately 80,000 new cases occur and some 5,000 persons die from chronic liver

problems related to hepatitis disease every year in the United States. Hepatitis B virus (HBV) is a blood-borne

disease and is commonly spread by contact with infected blood, needles, or by having sex with an infected person.

An infected woman can transmit the virus to her baby during birth. While all students should practice personal

behaviors that reduce risk exposure, the best protection against HBV is immunization. Most infants and school-

age children are now being routinely immunized. Most persons in the United States acquire HBV disease as

adolescents and adults. Thus, college students who have not been immunized should strongly consider

immunization.

For more detailed information, visit the websites for Centers for Disease Control (www.cdc.gov) or the American

College Health Association (www.acha.org). You may want to consult with your family physician or contact

your local health department to inquire about receiving immunizations. We wish you a healthy and rewarding

experience at the University of South Carolina Union!

SECTION B: Recommended Immunizations from the Centers for Disease Control and Prevention

1. Gardasil – Highly recommended for all females between the ages of 11 and 26 to prevent cervical cancer.

Date of first dose: ____/____/_____ Date of second dose: ____/____/_____ Date of third dose: ____/____/_____

2. Hepatitis B – Highly recommended for all students. Three doses of vaccine or positive Hepatitis B surface antibody.

 Three doses Hepatitis B series

Date of first dose: ____/____/_____ Second dose: ____/____/_____ Third dose: ____/____/_____  OR Three dose combined Hepatitis A and Hepatitis B series

Date of first dose: ____/____/_____ Second dose: ____/____/_____ Third dose: ____/____/_____  OR Laboratory/serologic evidence of immunity or prior infection (attach copy of titer and date)

3. Varicella – Either a history of chicken pox, a positive Varicella antibody, or two doses of vaccine given at least one month apart if immunized

after 13 years of age.

 History of disease verified by undersigned clinician Date of disease: ____/____/_____

 OR Laboratory/serologic evidence of immunity (attach copy of titer and date)

 OR One dose given at 12 months of age or later but before the student’s 13th^ birthday Date of dose: ____/____/_____

 OR Two doses. Dose 1 given after the student’s 13th^ birthday and Dose 2 given at least one month after first dose. Date of first dose: ____/____/_____ Date of second dose: ____/____/_____

4. Tetanus – Diphtheria – Pertussis – Primary series with DTaP, DTP, DT, or Td, and booster with Td or Tdap in the last ten years.

 1. Primary series of four doses with DTaP, DTP, DT, or Td:

Date of first dose: ____/____/_____ Second: ____/____/_____ Third: ____/____/_____ Fourth: ____/____/_____

 2. Booster: Tdap to replace a single dose of Td for booster with at least five years since last dose of Td. ____/____/_____

 3. Booster: Td within the last ten years ____/____/_____

Healthcare Provider (signature or stamp required)

Name: ___________________________________________ Signature: _______________________________________________________________________

Address __________________________________________________________________________________________________________________________

Street/P.O. Box City State ZIP

Phone (____) ____________________________________ Date__________________________________________________

SECTION C: Parental Consent (if student is under the age of 18)

I hereby authorize any medical treatment and/or counseling services for my son/daughter that may be advised or recommended by the healthcare providers and/or counselors at the University of South Carolina Union Campus.

Parent Signature (if student is under the age of 18): _____________________________________________________ Date: _________________

SECTION D: Immunization Exemptions

 This student is exempt from the above immunization on ground of permanent medical contraindication.  This student is temporarily exempt from the above immunizations until ____/____/_____

I, ________________________________________________ affirm by my signature below that immunizations required by the University of South Carolina – Union Campus is in conflict with my religious beliefs. I understand that I am subject to exclusion from the University in the event of an outbreak of a disease for which immunization is required.

Signature ________________________________________________________ OR

I, ________________________________________________ declare by my signature that I will ONLY be enrolling in courses offered by distance learning and therefore will not be attending ANY classes on the University of South Carolina – Union Campus. I understand that registering for a course offered on-campus or at a University owned or controlled facility voids this exemption and I will be excluded from class until I provide proof of immunizations. This exemption must be requested for each new term of registration for off-campus courses.

Signature ________________________________________________________