Student Immunization Form – Page 1 of 2

2014-2015

Hult International Business School, in compliance with Commonwealth of Massachusetts regulations and U.S. public health
recommendations, requires ALL STUDENTS to be immunized against certain communicable diseases. You must complete this
Immunization Form, no other forms of immunization proof will be accepted. Please keep in mind you are required to comply with
Massachusetts’s standards regardless of your home country’s immunization requirements or process. All test results must be in
English and accompanied with a key or rubric.

This documentation must be submitted within 30 days of orientation. Without it you will not be allowed to attend classes, jeopardizing
your academic standing and, if you are on a visa, affecting your immigration status. You may email an electronic version prior to your
arrival to student.services.boston@email.hult.edu or bring the completed document to orientation.

Section 1 (to be completed by student):

Name:
_________________________________________________________________________________________________________
Surname(s) Given Names(s) Middle Name(s)

Online Application ID: ____________________________

Section 2 – TDAP (to be completed by Health Care Provider):

Received one dose of tetanus, diphtheria and pertussis if last dose of Td was before 2009. If last dose of Td was within the last five
years please include that vaccination information below.

Print Name: _______________________________________________

Signature: _________________________________________________ Stamp: ________________________________

Date: ____________ / ____________ / ____________

Month Day Year

Section 3 – Varicella (Health Care Provider: complete Option 1 or Option 2, then complete bottom section)

Option 1: Received 2 doses of varicella vaccine (at least four weeks Option 2: Has laboratory evidence of immunity
apart)

I have attached documentation of a positive serological test

Dose 1: ____________ / ____________ / ____________ (immune titer or positive antibodies) to this form, or a
Month Day Year
statement signed by a physician, nurse practioner or physician
assistant that the student has a reliable history of chickenpox
disease
Dose 2: ____________ / ____________ / ____________
Month Day Year
Initials: ___________

Print Name: _______________________________________________

Signature: _________________________________________________ Stamp:__________________________________

Date: ____________ / ____________ / ____________

 Student Immunization Form – Page 2 of 2
2014-2015

Section 4 - MMR (Health Care Provider: complete Option 1 or Option 2, then complete bottom section)

Option 1: Received 2 doses of MMR vaccine (at least four weeks apart) Option 2: Has laboratory evidence of immunity

Dose 1: ____________ / ____________ / ____________ I have attached documentation of a positive serological test
Month Day Year (immune titer or positive antibodies) to this form.

Initials: ___________
Dose 2: ____________ / ____________ / ____________
Month Day Year

Print Name: _______________________________________________

Signature: _________________________________________________ Stamp:__________________________________

Date: ____________ / ____________ / ____________

Month Day Year

Section 5 - Hepatitis B (Health Care Provider: complete Option 1 or Option 2, then complete bottom section)

Option 1: Received 3 doses of Hepatitis B vaccine

Dose 1: ____________ / ____________ / ____________ Option 2: Has laboratory evidence of immunity

Month Day Year
I have attached documentation of a positive serological test
Dose 2: ____________ / ____________ / ____________ (immune titer or positive antibodies) to this form.
Month Day Year
Administered at least one month after the first dose
Initials: ___________
Dose 3: ____________ / ____________ / ____________
Month Day Year
Administered at least six months after the first dose

Print Name: _______________________________________________

Signature: _________________________________________________ Stamp: ________________________________

Date: ____________ / ____________ / ____________

Month Day Year