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Student Immunization Form 2017-2018

Hult International Business School, in compliance with Commonwealth of Massachusetts regulations and U.S.
public health recommendations, requires ALL STUDENTS to be immunized against certain communicable
diseases. Please keep in mind that students are required to comply with the standards of Massachusetts
regardless of the home countrys immunization requirements or process. All test results must be in English and
accompanied with a key or rubric.

This documentation must be submitted within 30 days of orientation. Attendance to class and academic
standing could be jeopardized, as well as visa and immigration status if proper documents are not submitted.
The completed form and documentation may be uploaded to the link posted on myHult or handed in during
orientation.

This document must be completed by a health-care provider or medical


records official.
The Massachusetts Department of Public Health requires full-time graduate students meet the following:
3 doses of hepatitis B vaccine or serologic proof of immunity to hepatitis B.
2 doses of MMR or serologic proof of immunity to measles, mumps, and rubella. Birth before 1957
in the United States is also acceptable.
1 dose of Tdap (or a dose of Td within the past 5 years).
2 doses of varicella vaccine or serologic proof of immunity or reliable history of chickenpox disease.
Birth before 1980 in the United States is also acceptable.

The only circumstances under which a student may be exempted from these regulations are as follows:
The student provides written certification by an examining physician that the students health would be
endangered by one or more of the immunizations. In this case, the student must submit laboratory evidence of
immunity to measles, mumps, rubella, and varicella (chickenpox); if the student is not immune, the student will be
excluded from classes in the event of an outbreak.
OR
The student provides a signed written statement that the required immunizations would conflict with his or her
religious beliefs. It is recommended that he or she present evidence of immunity through laboratory testing as
above. Otherwise the student will be excluded from classes in the event of an outbreak. Please note: parents
(including parents of minors) may not submit requests for religious exemptions on behalf of the student. The
student must provide a signed statement on his or her own behalf.

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Student Immunization Form 2017-2018
Student Name:
Last First Middle

Date of Birth: Program:


Month Day Year

Vaccines Dates Given Massachusetts State Requirements

2 Doses of MMR
MMR #1 __ / __ / ___ #2 __ / __ / ___
Minimum of 4 weeks between doses
OR
Measles
#1 __ / __ /___ #2 __ / __ / ___
Individual Vaccines:
Measles 2 Doses of each individual component
Mumps
Mumps (2 measles, 2 mumps, and 2 rubella)
#1 __ / __ /___ #2 __ / __ / ___
Rubella Minimum of 4 weeks between doses
Rubella
#1 __ / __ /___ #2 __ / __ / ___
OR
Positive Titers Please attach titer Positive titer

Tdap (tetanus, diphtheria, & pertussis) is


Tdap __ / __ /___ the only acceptable form of tetanus shot
(must be within last 10 years)

#1 __ / __ /___

#2 __ / __ / ___ Completed 3 part series


Hepatitis B
#3 __ / __ / ___
OR
Positive Titer Please attach titer Positive titer

Varicella #1 __ / __ / ___ #2 __ / __ / ___ 2 Doses of varicella vaccine


OR
Titer Please attach titer Positive titer
OR History of disease must be verified by
Disease Date of Infection __ / __ / ___
medical provider

Medical Provider Name MD/NP/PA (please print) Signature Date

Please provide physicians stamp:

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