The Board of Regents (BOR) of the University System of Georgia has established immunization requirements for all new students (first-year, transfers, and others) as directed by policy consistent with recommendations provided by the Advisory Committee on Immunization Practices, developed collaboratively by the Board of Regents of the University System of Georgia and the Division of Public Health of the Georgia Department of Human Resources.
A brief summary of current immunization requirements is available on the Board of Regents web site for your information.
Required Forms for New Students
Every newly admitted student must print, complete and submit each of the following forms:
- Certificate of Immunization
- TB Screening Questionnaire and TB Risk Assessment
- Medical Entrance
- All forms must be completed in English.
- Foreign language reports WILL NOT be accepted as well as handwritten lab results.
- Dates of immunizations or titers with results are required.
- All forms should be faxed to (912) 478-0792 or if you have registered for SOAR and can access my.georgiasouthern.edu, you can upload your documents in Online Student Health (OSH).
- All 3 forms should be submitted at least four weeks before your orientation date. Failure to do so may affect your ability to register for classes.
- Please keep a copy of all forms for your records.
- If you have any questions please email us at firstname.lastname@example.org
Certificate of Immunization Form
It is the policy of the Georgia Southern University’s Health Services to comply with the mandatory immunization program established by the Board of Regents of the University System of Georgia. These requirements include documented proof of immunity to measles, mumps, and rubella, varicella (chicken pox), tetanus, diphtheria, pertussis and hepatitis B, prior to registration at any college or university within the University System. For additional information, please visit the The Board of Regents.
No temporary clearances are given to allow registration without meeting these requirements.
Please note that dates of immunizations and titers with results are required. The physician or other healthcare provider must sign the form. Any request for consideration of exemption must have signed documentation attached.
Exemptions from immunization requirements are allowed on the following basis:
- Religious Objection
- Medical Reasons *Requires Physician’s certification (documentation required)
During a public health event such as an epidemic, the president of the university is authorized in conjunction with the Chancellor and appropriate health authorities, to put rules and regulations in place regarding diseases against which immunizations may be required.
Any individual who cannot show proof of immunity or adequate immunization and refuses to be immunized shall be excluded from any institution or facility of the University System until valid evidence is produced that they are immunized against the disease or the epidemic threat no longer constitutes a significant public health danger (BoR Minutes 1989-90, p.406).
In the event of a disease outbreak, these students may be excluded from any institution or facility of the University System until such time as they present valid evidence that they are immunized against the disease, have had the disease and recovered, or the epidemic or threat no longer constitutes a significant public health danger.
Tuberculosis (TB) Screening Questionnaire and TB Risk Assessment Form
Part I Tuberculosis (TB) Screening Questionnaire needs to be completed by you. All 6 questions must be answered. Country of birth must be circled if indicated. Your physician, healthcare provider or health services reviewer must complete and sign your form.
Part II Clinical Assessment by Health Care Provider is required ONLY if risk noted on TB Screening Questionnaire. This section must be completed by your physician or healthcare provider.
Part III Management of Positive TST or IGRA is required ONLY if risk noted on TB Screening Questionnaire. This section must be completed by your physician or healthcare provider.
Part IV Health Care Professional Signature is required ONLY if risk noted on TB Screening Questionnaire. This section must be completed by your physician or healthcare provider.
A person with any identifying risk factors must receive either one Mantoux Tuberculin Skin Test (TST) or have a blood test drawn for Interferon Gamma Release Assay (IGRA).
The form and results must be evaluated and signed by a physician or healthcare provider.
Results must be dated no more than 6 months prior to arrival on campus.
Eligible students may choose to complete the TB Risk Assessment on site at Health Services once on campus in Statesboro. Fees are charged for the IGRA. Health Services does not perform the TST to satisfy the TB Risk Assessment requirements.
Medical Entrance Form
Please provide all information requested. It is very important that we have any pertinent medical history available on file. You are reminded that the “Authorization to Treat” section must be signed. Students under 18 years of age are required to have a parent/legal guardian sign. Emergency contact information should be completed as well.
Last updated: 8/24/2016