To be completed by Physician or Health Care Provider 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the student's name, social security number, and date of birth in the designated fields.
3. Fill in the details for the first and second MMR vaccinations, including month, day, and year.
4. If applicable, provide information for Rubeola, Rubella, and Mumps vaccinations by filling out their respective sections.
5. Indicate proof of immunity through serologic testing or previous infections by checking the appropriate boxes and attaching necessary documents.
6. Complete the section for other recommended immunizations if relevant, noting dates for Td/Tdap, Polio, Varicella, and Hepatitis B series.
7. Ensure that a physician or authorized health care provider signs the document and includes their address and office stamp.
8. Finally, return the completed form to The University of Mississippi as instructed.

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