DUQUESNE UNIVERSITY HEALTH SERVICE

2ND FLOOR UNION 600 FORBES AVENUE

PITTSBURGH, PA 15282
PHONE (412) 396-1650
FAX (412) 396-5655
DUQUESNE UNIVERSITY IMMUNIZATION REQUIREMENTS

Welcome to Duquesne University!

Completion of the Immunization Verification Form is required and must be submitted electronically as per the steps outlined below.
Incoming new students for fall semester must do so by July 31 (and those admitted to begin classes in spring semester by January 5).

Submitting the IMMUNIZATION VERIFICATION FORM – IMPORTANT

This is a 2-step process. Please follow instructions for each step carefully and complete in the following order to ensure that your
records are processed without delay. ALL documentation must be in English.

Step #1: Take the Immunization Verification Form to your healthcare provider for completion.
The Form MUST contain the required immunization information as well as the provider’s signature, title, date, address, and
organization stamp. Individuals who submit the Immunization Verification Form with missing required information or who otherwise
demonstrate non-adherence to immunization requirement specifications will be deemed non-compliant. Please note that
recommended immunization dates should also be provided as requested. A physical examination is NOT required for admission to
Duquesne University.
Step #2: With your university issued credentials (student DORI user name) and multipass password (that you have created)*, log
into DORI and then the Health Service Student Portal and upload an image of the completed Immunization Verification Form (in
English) by selecting the Immunization Upload option from either “Upload” area in the portal. (Detailed instructions
below). Acceptable image file types are: PNG, JPG, JPED, GIF. PDF files are NOT acceptable due to security reasons. Keep the
original document in your home records.

*Sharing your student access password with anyone is against Duquesne University security policies.
Submission Steps:
1. After your healthcare provider has completed the Form, create image files of the document. Suggestions:
 Take a photo with a mobile device camera or other digital process, assuring that photo is clear. Save the image. Take
care to ONLY upload the image of the Immunization Verification Form, as uploaded images are permanently entered
directly into your electronic medical record.
 OR you may also SCAN the form if it is saved as an image file such as a JPG, JPEG, PNG, or GIF, under 4MB. There are
free scanning apps for most mobile devices.
2. Log into DORI through the Duquesne University website: http://www.duq.edu/dori using your student Multipass User Name
and Password.
3. Select STUDENT from GO-TO (next to name at top of page)
4. Select Health Service Student Portal (indented under Resources & Information section of Student News & Information Tab)
5. Follow instructions in text box. Select from top or bottom of page.
6. Select IMMUNIZATION VERIFICATION FORM from the “Choose document you are uploading” box in the drop-down below
the list of available options.

7. Choose “Select File” to add saved image of the immunization verification form.
8. Click SUBMIT.

Communication regarding non-compliance will be done via email notification from Duquesne University Health Service.
Should you encounter any technical issues with the online submission process, please email [email protected] and include the
student name & birthdate, and a description of the technical problem or error encountered.
Please visit our FAQ’s page regarding any further questions or concerns, for your assistance: http://www.duq.edu/life-at-duquesne/
health-recreation-and-wellbeing/health-service/health-service-student-portal-and-immunization-compliance-frequently-asked-questions

Thank you,
Duquesne University Health Service

Immunization Verification Form Page 1 of 2

 DUQUESNE UNIVERSITY HEALTH SERVICE
2ND FLOOR UNION 600 FORBES AVENUE
PITTSBURGH, PA15282
PHONE (412) 396-1650
FAX (412) 396-5655
DUQUESNE IMMUNIZATION VERIFICATION FORM
LAST NAME FIRST NAME DATE OF BIRTH (MM / DD / YYYY) DUQUESNE ID NUMBER

REQUIRED VACCINES: * = Required

* Measles, Mumps, Rubella MMR Dose 1 Measles Dose 1 Mumps Dose 1 Rubella Dose 1
REQUIRED for all degree-seeking students
Dose 1 MUST be given on or after 1st birthday ____ /____ /______ ____ /____ /______ ____ /____ /______ ____ /____ /______
Dose 2 must have been given at least 4 weeks after Dose 1 MM DD YYYY MM DD YYYY MM DD YYYY MM DD YYYY
MMR Dose 2 OR Measles Dose 2 Mumps Dose 2
2 doses of MMR vaccine
OR ____ /____ /______ ____ /____ /______ ____ /____ /______
Individual vaccines – 2 doses of Measles, 2 doses of Mumps, 1 dose of MM DD YYYY MM DD YYYY MM DD YYYY
Rubella
OR OR
Blood test titer results confirming immunity - (equivocal and negative results Measles Titer Mumps Titer Rubella Titer*Attached copy of
are NOT accepted) ____ /____ /______ ____ /____ /______ ____ /____ /______
lab results required
MM DD YYYY MM DD YYYY MM DD YYYY if providing titer
information
* Meningococcal Conjugate (MCV4) Meningococcal MCV4 Please specify vaccine type such as Menactra or Menveo
REQUIRED for students living in University Housing ____ /____ /______
One dose on or after 16th birthday MM DD YYYY _______________________________

RECOMMENDED (not required):

Hepatitis A Hep A Dose 1 Hep A Dose 2 Hep A Dose 3

____ /____ /______ ____ /____ /______ ____ /____ /______

MM DD YYYY MM DD YYYY MM DD YYYY
Hepatitis B Hep B Dose 1 Hep B Dose 2 Hep B Dose 3

____ /____ /______ ____ /____ /______ ____ /____ /______

MM DD YYYY MM DD YYYY MM DD YYYY
HPV HPV Dose 1 HPV Dose 2 HPV Dose 3 Please specify vaccine type such as Cervarix,
(Human Papilloma) Gardasil-4 or Gardasil-9
____ /____ /______ ____ /____ /______ ____ /____ /______
MM DD YYYY MM DD YYYY MM DD YYYY _______________________________

Meningococcal Men B Dose 1 Men B Dose 2 Men B Dose 3 Please specify vaccine type such as Trumenba
Serogroup B or Bexsero
____ /____ /______ ____ /____ /______ ____ /____ /______
MM DD YYYY MM DD YYYY MM DD YYYY _______________________________

Pneumococcal Pneumococcal Dose 1 Please specify vaccine type such as

13 or 23 Valent Prevnar 13 or Pneumovax 23
Recommended for students at an increased risk for ____ /____ /______
pneumococcal disease MM DD YYYY _______________________________

Tdap Tdap - Last dose Please specify vaccine type such Td Td - Last dose
(tetanus, diphtheria, and pertussis) as Boostrix or Adacel (tetanus, diphtheria)
[this is not the same as DTap] ____ /____ /______ ____ /____ /______
MM DD YYYY ________________________ MM DD YYYY
Varicella Vaccine Varicella Dose 1 Varicella Dose 2 Varicella Titer
OR Varicella Blood Titer Test *Attached copy of lab results required
(equivocal or negative results are NOT accepted) ____ /____ /______ ____ /____ /______
MM DD YYYY MM DD YYYY OR ____ /____ /______
MM DD YYYY

* = Required
* Date: * Healthcare Provider Name (please print): * Signature and Title: * Phone Number & Address:

* Organizational Stamp Please do not mail, fax, email us a copy of your immunization records as they will not be processed
without being uploaded along with a completed Duquesne Immunization Verification Form.

PROVIDER:
Provide this completed form and/or a copy of any blood titer tests confirming immunity to the student.

STUDENT:
Upload the completed Immunization Verification Form and all other related documents through the
University Health Service Student Portal.

03/2017 IMMUNIZATION VERIFICATION FORM Page 2 of 2