Immunization Form

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043 | F: 888-837-2146 | www.uaf.edu/chc
Immunizations Required for Housing at UAF
Please use this form to submit your immunization records if you are experiencing technical issues with the Patient Portal.

Per the Board of Regents' policy 09.11.010, all students living in high-density campus housing must provide immunizations.

Non-compliance will result in the cancellation of your housing assignment.

Immunization/Testing Requirements:
- Meningococcal (MCV4) -For students ages 16-20, Administered after the age of 16, required up to the age of 21 years old
- Tetanus (Tdap, Td) -Administered within the last 10 years
- 2 Doses of Mumps, Measles, Rubella (MMR)
- Tuberculosis Screening -PPD Skin Test or Blood Test Within the last 12 months)
Medical and Non-Medical Exemptions require additional documentation.

For Non-Medical Exemption, please contact the Office of Rights, Compliance and Accountability for further guidance. They can be reached at 907-474-7300 or email uaf-orca@alaska.edu

For Medical Exemption, please provide a letter from a medical provider indicating reason for exemption to be submitted for review by our Medical Director. A Medical Exemption form can also be accessed via our website under the 'forms' tab at https://www.uaf.edu/chc/files/forms/immunization-exemption-form-260611.pdf
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student UA Identification number?
Student's cell phone/ contact telephone number
xxx-xxx-xxxx
Do we have permission to leave a text or voicemail using the phone number listed above?
Student email address
example@example.com
Can we send a message from UAF SHCC to this email address?
Have you ever received immunizations in the State of Alaska?
If yes, do we have permission to pull your immunization record from VacTrAK?
ALL immunization documentation submittied needs to include

Student Name and Date of Birth on EVERY PAGE.
Please upload immunization records here. Please use the "Take Photo" options below if you need to submit pictures of the student's immunization records rather than uploading documents.

Browse Files

Cancelof
Take Photo of the student's immunization record confirming the data provided above.
Take an additional photo of the student's immunization record confirming the data provided above if needed.
The information I have provided is accurate.
My/the student's compliance with UAF Board of Regents' Immunization will be shared with UAF Residence Life.
I understand that if I am under the age 18, my legal guardian will need to sign this form.

By signing this form,

I hereby attest that I am submitting accurate information about my/the student's immunization status. I understand that UAF SHCC will share the status of my/the student's compliance with UA Board of Regents Immunization Policy with UAF Residence Life. For Alaskans, your signature indicates you are giving UAF SHCC permission to access your/the student's record in Alaska's Immunization Information System (VacTrak).
Student or guardian signature if the student is under age 18.
Student or Guardian Typed Name
Date of Student or Guardian Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Guardian contact phone number if student is under the age of 18.
xxx-xxx-xxxx
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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Immunizations Required for Housing at UAF