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Campus Health Center
Immunization Form
2015 – 2016


Wayne State University (WSU) requires that
your immunization records be on file in the
Campus Health Center (CHC) before you
move into your residence hall room.
WSU recommends that students come to
school fully immunized to protect their health
and the health of the WSU community.
Immunizations are one of the most effective
public health measures in preventing certain
communicable diseases.
When is the deadline to return the form?
Please return the completed form with a copy of
your immunization records at least 14 days before
move-in day.
How do I submit my immunizations to the
Campus Health Center?
How can I find my immunization records?
Contact your health care provider, your high
school or other institutions where immunizations
were required to request a copy of your
immunization record. If you are Michigan-born,
your immunization record should be on file with
the Michigan Care Improvement Registry (MCIR).
Contact your most recent health care provider or
your local health department to check for your
MCIR records.
Immunizations are available at CHC, and you may
schedule an appointment to receive them. It is
recommended that students get all immunizations
before arrival on campus to ensure they are
adequately protected when they arrive. Call (313)
577-5041 or visit health.wayne.edu for more
information on pricing and accepted insurance
plans.
How can I find out if I’ve had all the
recommended immunizations?
Students under 18 years old need written
parental consent to receive immunizations.
Ask your health care provider to review your
records, determine your needs (immunity against
many of the diseases listed below can be
determined through blood tests) and provide
recommended immunizations. You may also make
an appointment with one of the CHC providers to
review your immunizations and provide any
necessary immunizations,
If you are not 18 on or before move-in day,
please have your parent or guardian complete an
Enrollment Form (available at
http://health.wayne.edu/docs/EnrollmentForm.
pdf) and submit it with your vaccine record or
bring it to your vaccine appointment.
Which immunizations are recommended
for college students?

By mail or hand deliver to:
Campus Health Center
5200 Anthony Wayne Drive, Suite #115
Detroit, MI 48202
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*You may also fax the form and your immunization

records to (313) 577-9581 as long as the records
are legible.
*Late records may be submitted on move in day.
Does CHC give immunizations? Are there
fees for immunizations?
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
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Meningitis vaccine - Highly recommended for
all incoming first-year students living in
residence halls
Measles, Mumps and Rubella (MMR - 2
doses)
Chicken pox (Varicella) if you haven’t had the
disease already (2 doses)
Tetanus-Diphtheria-Pertussis (Tdap – 1
dose)
Hepatitis B (3 doses)
Human Papilloma Virus (HPV) for both males
and females through age 26 (3 doses)
Who can I contact for more information?
If you have additional questions:
Call us at (313) 577-5041;
Email [email protected]; or
Visit our website: health.wayne.edu
Student Information: (Please print/type)
_________________________________________
___________________________________
________
Last Name
First Name
M.I.
_________________________________________
___________________________________
Date of Birth
Gender
_________________________________________
___________________________________
Residence Hall
WSU Student ID#
Room #
Please read the following statement and initial:
___ I understand that WSU Housing will be notified that I have or have not turned in my immunization record according to Wayne State
University policy.
Please select one of the following:
An official copy of my immunization record is attached (copy of: MCIR record, immunization card, or medical record)
I have already submitted my immunization record to Campus Health Center: Month and Year submitted____________
I do not have a record of my immunization history and am unable to provide the requested information to the Campus Health Center at Wayne
State University. I acknowledge that it is Wayne State University policy to submit a completed immunization record to the Campus Health
Center.
________________________________________________________
Student Signature
Date
____________________________________________________
Parent/Guardian signature (if student is <18)
Date
Return this form with your official immunization record attached at least 14 days prior to move in to the following address:
Campus Health Center
5200 Anthony Wayne Drive, Suite 115
Detroit, MI 48202
Or Fax to (313) 577-9581