Immunization Record Form - Montana State University

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Student Health Service
MSU-Bozeman PO Box 173260
Bozeman, MT 59717-3260
Telephone: (406) 994-2311
Fax: (406) 994-2504
MSU Student Health Service Immunization Record
Part I ~ IDENTIFICATION ~ Please Print or Type
Name:
Student ID#
Address:
Street
City
State
Zip
Telephone #
Birthday_____/______/_______
Sex:
M / F
Email Address
Father's Name:
Mother's Name:
Person to Notify in case of Emergency
Emergency contact:
Emergency contact:
Name
Phone/Cell Phone
Part II ~ TO BE COMPLETED AND SIGNED BY YOUR HEALTH CARE PROVIDER
Your high school, private physician, or city health department may be able to help you find proof of your vaccinations.
We will gladly accept a copy of your records as proof of vaccination, but please include your full name (as it appears on your
MSU application), Date of Birth, and your MSU ID # when you send it to us. Religious or medical exemptions can be granted if appropriate.
All information must be in English.
REQUIRED IMMUNIZATIONS
The following immunizations are either required or recommended by state law or MSU policy. This information must be from your physician's
records, or other official immunization records and signed by a medical professional. Deadline: One week before attending your scheduled
Orientation Program.
A. MMR (MEASLES, MUMPS, RUBELLA)
(Two doses required at least 28 days apart for students born after January 1, 1957. Any given before 1968 are not considered adequate.
Dose 2 must be given after 1980.)
#1 _____/_____/_____
1. Dose 1 given at age 12 months or later
M
D
Y
#2 _____/_____/_____
2. Dose 2 given at least 28 days after first dose
M
D
Y
B. TUBERCULOSIS Screening Form ~ see form. Testing may or may not be required.
The following immunizations are recommended, but not required for admission to MSU.
Please fill in all of the immunizations that student has received.
C. MENINGOCOCCAL QUADRIVALENT
(A, C, Y, W-135)
Quadrivalent conjugate
Dose #1 _____/_____/_____
Dose #2 _____/_____/_____
M
D
Y
M
D
Y
D. TETANUS, DIPHTHERIA, PERTUSSIS
1. Primary series completed? Yes_____ No_____
Date of last dose in series: _____/_____/_____
M
D
Y
2. Date of most recent booster dose: _____/_____/_____
M
D
Y
Type of booster: Td_____
Tdap_____
Tdap booster recommended for ages 11-64 unless contraindicated.
(Continued)
(Continued)
The following immunizations are recommended, but not required for admission to MSU.

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