Login to the UMass Patient Portal at https://umass.medicatconnect.com and go to the Uploadpage to upload this form and all supporting documents (immunization and titer records).Enter dates of vaccinations or titer results into fields on the Patient Portal Immunization page.

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__________________________________________________________________________Last Name First Name Date of Birth Student ID #

REQUIRED IMMUNIZATIONS 2021-2022Massachusetts state law requires submission of the following immunizations or proof of immunity for

admission. Have your healthcare provider complete and sign this form, or attach immunization documentsfrom your provider, school or military sources in lieu of signature.

(413) 577-5000 www.umass.edu/uhs

If there is a medical contraindication to any immunization, explain: _______________________________________________________________________________________________________________________________________________________________________________________________________

Healthcare provider signature: _____________________________________________________________________________ Date:__/__/__Printed Name Signature