Thomas More University International Immunization Form PDF
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Thomas More University
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Summary
This document is an immunization form for international students applying to Thomas More University. It requires proof of various vaccinations, including measles, mumps, rubella, Tdap, Varicella, Meningococcal, Hepatitis B, and others. Students must submit the form with supporting documentation from their physician.
Full Transcript
Return All Forms to: Thomas More University International Admissions 333 Thomas More Parkway, Crestview Hills, Kentucky 41017-3495 USA...
Return All Forms to: Thomas More University International Admissions 333 Thomas More Parkway, Crestview Hills, Kentucky 41017-3495 USA Phone: 859-344-3332 Email: [email protected] www.thomasmore.edu/admissions INSTUCTIONS TO APPLICANT: To create your Form I-20, Thomas More University International Admissions must receive proof of immunizations. Required immunizations are listed below and this form must be completed by a doctor or physician and have a physician’s signature or stamp. Personal Information: Please put your name in full as it appears on your passport. Family/Surname: _____________________________ First/Given Name: ________________________________ Middle Name: ________________________ Date of Birth (month/day/year): _______/_______/___________ Country of Birth: ________________________________ Country of Residence: ____________________________ Are you currently in the U.S.? ____ Yes ____ No REQUIRED IMMUNIZATION INFORMATION: Please indicate the date (MM/DD/YYYY) that you received the following vaccinations. It is required that you receive these immunizations before Thomas More University can create your I-20. ❖ MEASLES, MUMPS, RUBELLA (MMR) or (MR) measles, rubella Dose 1 given on____/_____/_____ (Should be given at least 12 months after first birthday) Dose 2 given on____/_____/_____ (Should be given 30 days after Dose 1) OR (Measles (Rubella) titer - blood test showing immunity) ❖ Tdap for whooping cough (Adacel and Boostrix): Immunized on _____/_______/_______ ❖ Varicella or evidence of chicken pox written form from health care professional: Immunized on ____/_____/_______ or had disease on ____/_____/________ ❖ Meningococcal (Menactra) Immunized on ______/______/_______ ❖ HEPATITIS B: Immunized on__________/____________/___________ (must have started HEP B series. If you have a full series, please submit immunization records) ❖ TUBERCULOSIS* QuantiFERON blood test given on____/_____/_____ with the following results: __________ *Tuberculosis QuantiFERON/IGRA must be done within 5 (five) months prior to enrolling at Thomas More University. If starting school in August, you should have the blood test done no earlier than March. If enrolling in January, blood test should be done no earlier than August. TB positive results will require a follow-up chest x-ray. All results must have the physician’s signature and be sent to Thomas More University. OPTIONAL IMMUNIZATION INFORMATION: Please indicate the date (MM/DD/YYYY) that you received the following vaccinations. It is recommended that you receive these immunizations before entering the United States. ❖ POLIO: Immunized on _______/_______/______ and ________/________/________ and ________/_______/_______ and _______/______/_____ ❖ HEPATITIS A: Immunized on________/________/_________and __________/__________/__________ ❖ PNEUMOCOCCAL: Immunized on__________/__________/_________ ❖ COVID-19: Immunized on_______/________/______ and _____/_____/______ SIGNATURE OF DOCTOR: ______________________________________________________________ This form will not be accepted without a doctor’s stamped credentials Please stamp or seal document here
