Professional Documents
Culture Documents
REQUIRED IMMUNIZATIONS
2018 – 2019
Massachusetts state law requires submission of the following immunizations or proof of immunity for
admission. Have your healthcare provider complete and sign this form, or attach immunization documents
from your provider, school or military sources in lieu of signature.
1. Upload this form and all supporting documents (immunizations and titer records) using the UHS
patient portal.
2. Enter dates of vaccinations or titer results into fields in the patient portal. Go to: https://
umass.medicatconnect.com
Individual vaccines or positive titers #1 / / #2 / / First dose given after first birthday
or Positive titer – date: / /
Measles -or-
#1 / / #2 / / Individual vaccines
Mumps or Positive titer – date: / /
-or-
#1 / / #2 / / Positive titers (blood tests for
Rubella or Positive titer – date: / / immunity)
ALERT: The UMass Amherst campus is considered to be in an outbreak status due to cases of
Meningococcal B – we strongly recommend all undergraduate students get vaccinated with either Bexsero
or Trumemba.
Meningococcal Group B
#1 / / #2 / / Two doses at least one month apart
MenB-4C (Bexsero®)
-or- -or-
-or- #1 / / #2 / /
MenB-FHbp (Trumenba®) Three doses at zero, two and six
#3 / / months
Menomune®
Hepatitis A
#1 / / #2 / /
Other vaccinations:
Date: / /
Influenza
Pneumonia Date: / /
Typhoid Date: / /
Other: Date: / /