Florida International University

Measles and Rubella Immunization Requirements
Must be Satisfied Prior to Registration

Check one Statement:

_____     I was born after December 31, 1956.  You are required to show proof of immunity to Measles and Rubella (German Measles) before you will be able to register for classes.
MEASLES:  You must satisfy one of the three conditions listed below:
a) Two (2) doses of measles vaccine - the first dose given after your first birthday and both given in 1968 or later.  The second dose must be no less than 30 days after first dose.
b)  A copy of blood test showing the presence of measles antibody (attach lab report to this form).
c)  Present a written note on letterhead from your physician stating that you had the natural measles disease.
RUBELLA:  You must satisfy (a) or (b) below:
a)  You need one dose of Rubella vaccine - one given in 19669 or later, after your first birthday.
b)  A copy of  blood test showing the presence of Rubella antibody (attach lab report to this form).
                       Note:   Having the natural Rubella disease is NOT acceptable proof.

OR

_____  I was born before before 1957 and I am less than 40 years old.
You are only required to show proof of immunity to RUBELLA.

OR

_____  I am 40 years of age or older.
You do not need to meet these requirements.

For your convenience, please have your physician complete and sign the form below and return to:
FIU Student Health & Wellness Center, 3000 N.E. 151 St., North Miami, FL 33181-3000.
Phone: (305) 919-5675   Fax: (305) 919-5312

Name ___________________________________________________    Date of Birth ______/______/______
                                                                                                                                             month       day      year

Student No. or S.S. # ___________________________

According to my records, the above-mentioned patient has received the following vaccines on the dates indicated below:

MEASLES VACCINE (two doses required more than 30 days apart)

Date 1: ______/______/______           Date 2: ______/______/______
             month       day       year                           month       day       year

RUBELLA (one dose required)       Date: ______/______/______
                                                               month       day       year
      OR
MMR vaccine:   1^st dose ______/______/______      2^nd dose ______/_______/______
                                         month      day        year                         month       day         year

_________________________________       ________________________________     ______/______/______
(Physician"s Office Stamp REQUIRED!)          Physician's Signature                                     Date

Address: _______________________________________________________________________________________
                 Street Address                                                                    City and Country                                Tel. No.

Note: Measles and MMR vaccines are available at the FIU Student Health & Wellness Center at each Campus.

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