Immunization Form - University of Utah - School of Medicine 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information at the top of the form, including your name, date of birth, employee UID#, and department ID#. Ensure accuracy as this information is crucial for verification.
3. Proceed to the 'Two Step TB Skin Testing' section. Document the dates for TST #1 and TST #2, ensuring that TST #2 is placed no sooner than 7 days after TST #1. Remember to self-evaluate and sign off if there are no adverse reactions.
4. Fill out the immunization history sections for MMR, Varicella, Hepatitis B, Tdap, and Influenza. Provide documentation as required for each vaccine or titer result.
5. Finally, review all entries for completeness and accuracy before signing at the bottom of the form. This signature confirms that you understand the verification process.

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