Student Immunization Record Part I Student Information
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1 Student Immunization Record Part I Student Information Student ID#: Last Name: First Name: _ MI: Date of Birth: Sex: Phone Number: Parts II - IV are to be completed by a Healthcare provider. All dates must include MONTH, DAY and YEAR. Part II Measles, Mumps, Rubella Students born on or before January 1, 1957 will not have to provide immunity for MMR MMR #1 Date of Vaccine _ / / (must be given on or after 12 months of age/first birthday) MMR #2 Date of Vaccine _ / / (must be given at least 28 days after MMR #1) - OR - If individual vaccines were received for Measles, Mumps, and Rubella, please complete the following: Measles (Rubeola) Vaccine Date of Vaccine # 1 / / Rubella (German Measles) Vaccine Date of Vaccine # 1 / / Mumps Vaccine Date of Vaccine # 1 / / If proof of vaccine cannot be provided, a student must obtain a blood titer to confirm immunity of any of the above. A copy of the laboratory test in English must be submitted.
2 Student ID#: _ Part III Tetanus/Diphtheria/Pertussis (DPT,DTP,DT,DTap,Td or Tdap) All students must show proof of vaccination of three (3) dose dates for Tetanus/Diphtheria/Pertussis immunization One dose must be a Tdap (tetanus, diphtheria and acellular pertussis) vaccine One dose must have been given within 10 years of first date of Summer Study Tetanus Toxoid vaccine is not acceptable in fulfilling this requirement Date of Vaccine # 1 / / DPT, DTP, DT, DTap, Td or Tdap Date of Vaccine # 2 / / DPT, DTP, DT, DTap, Td or Tdap Date of Vaccine # 3 / / DPT, DTP, DT, DTap, Td or Tdap Part IV Meninococcal Vaccine (Menactra MCV4, Menomune MPSV4, Menveo or Meningococcal) Required for all new students under the age of 22 One dose must have been given on or after 16 th birthday Part V Polio All students must show proof of vaccination of four (4) dose dates for polio immunization Fourth dose must be given on or after the 4 th birthday and 6 months after the previous dose, or a 5 th dose is required Three doses are acceptable if the 3 rd dose is given on or after the 4 th birthday and 6 months after the previous dose. Date of Vaccine # 1 / / Date of Vaccine # 2 / / Date of Vaccine # 3 / / Date of Vaccine # 4 / / Part IV Varicella Two (2) doses; first dose must be given on or after the 1st birthday and 2nd dose must be given 28 days after dose 1 A reliable history of chickenpox or laboratory evidence of immunity acceptable
3 Student ID#: _ Part V Hepatitis B 3 doses are required Laboratory evidence of immunity is acceptable Date of Vaccine # 1 / / Date of Vaccine # 2 / / Date of Vaccine # 3 / / Provider(s) Signature: Provider(s) Printed Name: Address: Phone Number: Healthcare Provider Certification
4 Compliance Services Quick Reference Sheet for Students Compliance Services allows students to enter their own health information into the Babson College Summer Study secure online student portal. This information is verified and approved by a health administrator who can track compliance or lack of compliance and report back to the student through secure messaging. Compliance Services makes it easy to check that student requirements are satisfied and generate reports which track and monitor student immunization activity. This sheet is a quick guide to some common issues that arise for students using Compliance Services. Accessing the Babson College Summer Study Secure Online Student Portal Using any browser on a computer or mobile device, go to Students will use their Babson address and student ID to access the online systems for Compliance Services. See your enrollment for more information about these credentials. Should you not have these credentials or have forgotten the password, please contact SummerStudy@babson.edu. If there is any other difficulty accessing the secure online student portal, please complianceservices@medicat.com. Compliance Services will respond to all student inquiries by within one business day. Entering Immunization Records on the Compliance Services Management System Each student is responsible for accessing the Babson College Summer Study secure online student portal to enter accurately the information on their Immunization Record. It is recommended that all vaccinations on the record are entered where available but it is only necessary to enter the records for vaccinations required by Babson College Summer Study. Uploading Immunization Documents Documents that are uploaded directly must be in one of the following formats:.gif,.png,.tiff,.tif,.jpg,.jpeg,.txt, or.pdf. Please make sure that your file name consists of only alpha and numeric characters in the file name. No extra spaces permitted. We do not support any Microsoft Word files such as.doc,.docx or.docm formats. After Submission Documents uploaded via the Babson College Summer Study secure online student portal are available immediately for review. It typically takes 5 business days to process immunization records. Once records have been successfully matched, students will be notified by . Checking your Status Navigate to Immunization on the left hand tab of the home screen. Select View History and Status and you can view your status along with a description of each status. Requirements
5 Each student is responsible for understanding the requirements of their institution. Each student is responsible for meeting the submission deadlines set by their institution and understanding that the consequences of not satisfying the requirements could include termination. All supporting documentation must include a student s full name (first and last) and their birthdate for verification purposes.
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