LAST NAME FIRST NAME MIDDLE
DATE OF BIRTH mm/dd/yyyy UNIVERSITY ID # SEMESTER START (CHECK ONE):
FALL SPRING SUMMER 20______
2847 Union Drive
Ames, Iowa 50011
Phone: 515-294-5801
Fax: 515-292-9135
IMMUNIZATION REQUIREMENTS - INTERNATIONAL STUDENT
06/23
(continued on second page)
REQUIRED IMMUNIZATIONS
Measles: Iowa State University requires that all new (including transfer and graduate) students born on or after January 1, 1957, show proof of immunization or
immunity to measles. Measles immunizations may be found on your immunization record listed as Measles, MMR, MR, or Rubeola (titer).
RECOMMENDED IMMUNIZATION
Meningitis : The State of Iowa requires that all colleges and universities provide information on the meningitis vaccination to incoming students. If you will be living
in the residence halls, it is recommended by the CDC that you receive this vaccination. This vaccination is not required, but it is recommended.
There are two different immunizations needed to protect against Meningitis. One protects against Meningitis serogroups A, C, W, and Y. The other vaccine protects
against Meningitis serogroup B. We recommend our students receive both vaccines to protect against all vaccine preventable serogroups of meningitis.
Meningitis
MCVY
mm/dd/yyyy mm/dd/yyyy
Meningitis B
mm/dd/yyyy mm/dd/yyyy
Bexsero or Trumemba
Option 1
Measles
Dose 1 mm/dd/yyyy Dose 2 mm/dd/yyyy
Option 2
Positive (+)
Rubeola IgG
mm/dd/yyyy mm/dd/yyyy Lab report attached
Option 3
DOCUMENTATION OF WAIVER
Submit proof of religious or medical exemption by attaching the appropriate Iowa Department of Public Health Exemption to
this signed document.
MEASLES
Vaccinne must be given at least 28 days apart and after 12 months of age. Two (2) measles doses required OR positive measles titer). Doses administered at
less than the minimum interval or earlier than the minimum age are not valid and must be repeated. Complete one of the options below.
MMR
MR
MEASLES
MMR
MR
MEASLES
IMMUNIZATION REQUIREMENTS - INTERNATIONAL STUDENT (PAGE 2/2)
LAST NAME FIRST NAME MIDDLE
DATE OF BIRTH mm/dd/yyyy UNIVERSITY ID #
TUBERCULOSIS SCREENING
Tuberculosis (TB) is caused by a bacterium called mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of
the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal. For basic facts on tuberculosis, please visit the Center for Disease
Control and Prevention’s tuberculosis page.
It is recommended by the CDC for any incoming student who has traveled internationally to areas of high risk for tuberculosis, be screened for this illness. All
incoming students will be prompted to answer questions regarding TB exposure below.
Iowa State University Thielen Student Health Center follows the World Health Organization guidelines for TB testing. Iowa State does NOT require you to
complete testing prior to your arrival. If TB testing is indicated, it will be performed during your health screening orientation session.
COUNTRY OF ORIGIN:
HISTORY OF PREVIOUS TB TESTING
IGRA
Interferon Gamma
Release Assay
Result mm/dd/yyyy
Positive Negative Indeterminate
Treatment, if
positive:
TB SKIN TEST
Result mm/dd/yyyy
Positive Negative Indeterminate
Treatment, if
positive:
Countries and dates traveled to in the last 5 years. Only include those where you stayed longer than 90
days, or stayed longer than 30 days and were a healthcare worker, refuge camp volunteer or prison worker.
Country of Origin Risk Status Chart
06/23
LICENSED MEDICAL PROVIDER VERIFICATION
Provider Printed Name: Phone _____________________________
Provider Signatures/Credentials ______________________________________________ Date
First Last
Once this form is completed, follow the Vaccination Requirement Instructions
available at health.iastate.edu, under “New Students” and “Vaccination Requirement”.
Students can attach original and signed documents for immunizations/testing listed above in lieu of signature below. Original documents must be translated
and include your name and date of birth.
