Summer Intern Immunization Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

PNW Housing Immunization Requirements

It’s easy to submit your vaccination information! You can use the same immunizations you submitted for your current University, HOWEVER, they may not require the same immunizations as PNW.

Required Immunizations:

-Two (2) doses of MMR (Measles, Mumps, and Rubella) received AFTER 1st birthday

-TDAP or TD booster within the last ten (10) years

-Meningococcal Conjugate (MCV4) on or after 16th birthday

-Meningococcal B (if 25 years and younger)*

*The Meningococcal B vaccination is a two-dose series with a waiting period of 1-6 months between doses (depending on brand).

**International students must also submit results from a Tuberculosis (TB) test**

THESE MUST BE COMPLETED BEFORE YOU MOVE IN!

Please fill in the dates below of when you received each of the required vaccines

Name *

Birthday *

YYYY

Email *

Are you an international or domestic student? *

International (non-US Citizen)

Domestic (US-Citizen)

MMR (measles, mumps, and Rubella) Dose 1 date: *

YYYY

MMR (measles, mumps, and Rubella) Dose 2 date: *

YYYY

TDAP or TD booster date (Must be within the last 10 year): *

YYYY

Meningococcal Conjugate (MCV4) date (on or after 16th birthday) (if 23 years and younger): *

YYYY

Meningococcal B First Dose: (if 23 years and younger)

The Meningococcal B vaccination is a two-dose series with a waiting period of 1-6 months between doses (depending on brand). Interns within the medical waiting period may move into University Village prior to completing the series, but will need to email proof of 2nd dose as soon as medically possible.

YYYY

Meningococcal B Second Dose: Interns within the medical waiting period may move into University Village prior to completing the series, but will need to email proof of 2nd dose as soon as medically possible. *

YYYY

TB Test (Required for all International students):

YYYY

Please provide any additional information you would like us to know.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Purdue University Northwest. Report Abuse

Forms