Get Immunization Form - Haskell Indian Nations University - Haskell

Completing the Immunization Form for Haskell Indian Nations University is an important step in ensuring that health records are accurate and up-to-date. This guide offers a clear, step-by-step approach to help users fill out the form correctly.

Follow the steps to fill out the Immunization Form online.

1. Press the ‘Get Form’ button to access and open the Immunization Form in the editor.
2. Begin by entering the last name, first name, and middle name of the applicant in the designated fields.
3. Input the date of birth in the appropriate format, ensuring clarity about month, day, and year.
4. Include the social security number in the provided space. This information is required for identification purposes.
5. Enter the address of the applicant accurately, providing a complete mailing address.
6. Proceed to the required vaccinations section. Here, record the month, day, and year for each dose of the MMR vaccine received. Indicate whether the 2nd dose was administered after 1989 based on the applicant's birth year.
7. In the recommended vaccinations section, record the dates for Tetanus & Diphtheria, Polio, Meningitis, Varicella, Hepatitis B, and Hepatitis A vaccines. Ensure accuracy in documenting the month, day, and year each dose was received.
8. A medical or designated personnel must certify the vaccination record. Ensure the signature, printed name, title, and address of the certifying individual are included.
9. If applicable, complete the statement of exemption for religious or medical conditions, ensuring the required signatures are provided. A medical exemption must be signed by an MD or DO.
10. After filling in all required and recommended fields per the instructions, users can save their changes, download, print, or share the form for submission.

Complete your Immunization Form online today to ensure your health records are submitted correctly.