Counseling and Health Services

Counseling and Health Services

3400 S. 43rd Street, AF203 Milwaukee, WI 53234

Fax 414-382-6192

Immunization Form for Resident Students

Student Name:______

Date of birth: ______Phone:______

Students must complete an Immunization Form and return it to Health Services. Students who do not turn in a complete Immunization Form may be asked to leave the residence hall in the event of a vaccine-preventable disease occurrence in Milwaukee, Wisconsin.Residents are responsible for reading the Vaccine Information Sheets provided as part of the online housing contract. This form must be completed and returned to Health Services. Please include the month, date and year of each immunization.

If you were immunized in the state of Wisconsin, your vaccinations may have been recorded through the Wisconsin Immunization Registry: .

Immunization / Type / Date / Date / Date
**Most recent date
Tetanus Diptheria
(Td) / Booster every 10 years / __/__/__
**Most recent date
Pertussis / Booster every 10 years / __/__/__
Measles
Mumps
Rubella
(MMR) / 1 dose after 1st birthday, 2nd dose after 4th birthday / __/__/__ / __/__/__
Varicella
(Chicken Pox) / Indicate date of immunizations / __/__/__ / __/__/__
Varicella
(Chicken Pox) / Indicate date of disease / __/__/__
Hepatitis B / Recommended, but not mandatory / __/__/__ / __/__/__ / __/__/__
Meningitis / Recommended, but not mandatory / __/__/__

By federal law, each year all resident students must acknowledge that they have been informed about the risks and benefits of receiving the Meningitis and Hepatitis B vaccinations. These vaccinations are recommended, but not mandatory. If students want to have these vaccinations they may do so, at their cost, through their primary care physician or their local public health agency. Some vaccinations are available through Alverno College Health Services—students may call Health Services at 382-6319 to inquire about the cost and availability.

By signing this form, I agree with the following statements:

I have received and read the Meningitis and Hepatitis B vaccine statements.

I accept full responsibility (financial, legal, medical, academic) for waiving any missing immunizations, including off campus living arrangements and fees and/or penalties assessed by the College for missed classes.

I affirm that the above is true to the best of my knowledge.

Signed:______Date:______

Return form to:Mary Reese, Nurse, Health Services

PO Box 343922Milwaukee, WI 53234-3922

Phone: (414) 382-6319Fax: (414) 382-6192

Email: