IMMUNIZATION HISTORY AY2024-2025
75 Mount Auburn Street,
Cambridge, Massachusetts 02138
NON-HEALTHCARE & NON-CLINICAL
HEALTHCARE PROGRAMS
Last Name :
First Name :
Date of Birth : / / HUID :
School :
The Commonwealth of Massachusetts and Harvard University require students with an on-
campus presence and all students on a visa to be immunized against certain communicable
diseases. All dates entered must include month, day, and year. To comply, have this form
completed and signed by your healthcare provider. Once completed by provider, student is to
upload all documents to the Patient Portal as soon as possible.
Documents uploaded less than 10 -15 business in advance of student’s registration date, risk not
being processed on time for course registration.
Harvard and Massachusetts
Required Vaccine Dates Given
State Requirements
____________________
month / day / year
One dose of flu vaccine on or
after 7/1/2024 (Harvard
Manufacturer_____________________
Annual Influenza requirement).
Vaccination
This year’s influenza vaccination must be completed
Please upload to the Patient
after July 1, 2024. Vaccines before 7/1/2024 are not
Portal as soon as received.
acceptable.
#1 _________________ #2 _________________
month / day / year month / day / year
Hepatitis B Dose #1: any age
Series of 3 immunizations #3 _________________ Dose #2: 1 month after
– a positive serological test month / day / year dose #1
(titer) for immunity is Dose #3: at least 6 months
acceptable in lieu of OR Positive Titer Date: ________________ after dose #1
immunization. month / day / year
If Twinrix, check here
Measles-Mumps-Rubella
(MMR) #1 _________________ #2 _________________
Series of 2 month / day / year month / day / year
Two immunizations on or after
immunizations – a
the first birthday (age 1), at
positive serological test
least 28 days apart.
(titer) for immunity is OR Positive Titer Date: _________________
accepted in lieu of month / day / year
immunization.
Page 1 of 3
IMMUNIZATION HISTORY AY2024-2025
75 Mount Auburn Street,
Cambridge, Massachusetts 02138
NON-HEALTHCARE & NON-CLINICAL
HEALTHCARE PROGRAMS
Harvard and Massachusetts
Required Vaccine Date(s) Given
State Requirements
_________________
Meningococcal One dose on or after age 16
month / day / year
Required for students 21 (required for students age 21
years old and younger. years and younger).
A-C-W-Y strains, strain “B” is not sufficient.
Tetanus/Diphtheria/
One dose of Tdap within the
Pertussis (Tdap) _________________
last ten years (Harvard
TD does not fulfill this month / day / year
requirement)
requirement.
#1 _________________ #2 _________________
Dose #1: on or after the
month / day / year month / day / year
first birthday (age 1)
Dose #2: at least 28 days
Varicella Vaccination OR OR Positive Titer Date: _________________
after dose #1
History of Chickenpox month / day / year
OR if born in the USA
Series of 2 immunizations
before 1980, you may waive
– a positive serological test Age: ____________ OR
by initialing here: ________
(titer) for immunity is
Medical record
accepted in lieu of Date of Disease: _________________
documentation signed by
immunization. month / day / year
provider required for
history of chickenpox
Varicella vaccination must have been administered on or
illness.
after March 1995.
Strongly Recommended Massachusetts State
Date(s) Given
Vaccine Recommends
Gardasil (HPV) 3 doses over 6 months.
2 doses.
Hepatitis A Dose #2, 6 months after dose
#1.
Booster dose of injected polio
Polio (most recent dose) vaccine following completion of
primary series
Travel-Related
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IMMUNIZATION HISTORY AY2024-2025
75 Mount Auburn Street,
Cambridge, Massachusetts 02138
NON-HEALTHCARE & NON-CLINICAL
HEALTHCARE PROGRAMS
Strongly Recommended Massachusetts State
Date(s) Given
Vaccine Recommends
Date: _____________
month / year
TB SkinTest/Blood Test Baseline history.
Negative Positive
Repeat series every:
Typhoid Oral IM 5 years-Oral
3 years-IM
Repeat vaccination every 10
Yellow Fever
years.
Signature and stamp of physician/nurse practitioner/physician Date
assistant/school official
PHYSICAL SIGNATURE & STAMP REQUIRED
The only circumstances under which a student may be exempted from the Massachusetts
Immunization Law are as follows:
Certification in writing by an examining health care provider who is of the opinion that the
student’s physical condition is such that their health would be endangered by one or more of the
immunizations. The student will be required to submit laboratory evidence of immunity to
measles, mumps, and rubella; if not immune, they will have to leave campus in the event of an
outbreak; OR
The student states in writing that the required immunizations would conflict with their religious
beliefs. It is recommended that they present evidence of immunity, as above. Otherwise, they
will have to leave campus in the event of an outbreak.
Student to complete Student Vaccine Exemption form. The Massachusetts Department of Public
Health requires the waiver to be renewed annually.
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