Immunization Forms

IMMUNIZATION RECORD FORMS

The following forms can be downloaded and completed at your convenience.   They are arranged by specific student groups.   Please follow form requirements listed next to each link.


Incoming Students
Incoming students are considered to be enrolled students attending the University of Pittsburgh for the first time.   This form must be completed and returned to the Health Service prior to start of the first term by all incoming students.   ** Required by all incoming students NOT governed by special program immunization requirements.
•     Incoming Student Immunization Form (PDF)
•     Immunization Exemption Form (PDF)


Special Circumstance
•     Hepatitis B Refusal Form (PDF)

 

Special Programs –     School of Health and Rehabilitation Sciences

** School of Health and Rehabilitation Sciences forms are no longer available for download from this site.   Please contact the School of Health and Rehabilitation Sciences about their specific forms and procedures.


Special Programs – School of Nursing

** School of Nursing forms are no longer available for download from this site.  These forms can be obtained from the School of Nursing – Student Services Office (Rm 239), if you did not receive them via U.S. Mail.

** Required by all Nursing students.

•     Nursing Initial Health Form
•     Nursing Annual Health Form


 ATTENTION
Any completed immunization or health forms from this page must be promptly returned to the Health Service for processing.


Please send student immunization forms or health forms using one of the preferred methods below:

U.S. MAIL:   University of Pittsburgh
Student Health Service
Nordenberg Hall – Wellness Center
119 University Place
Pittsburgh, PA. 15260
FAX:  412-383-1846
EMAIL: jdw30@pitt.edu