Student Immunization Form printable pdf download

Student Immunization Form

FOR SCHOOL USE ONLY

(

) Complete; booster required in ___________

Student Name _________________________________________________

(

) In process; 8 mos. expires _____________

Birthdate _____________________Student Number __________________

(

) Medical exemption for _________________

(

) Conscientious objection for _____________

Minnesota law requires children enrolled in school to be immunized against certain

(

) Parental/guardian consent _____________

diseases or file a legal medical or conscientious exemption.

Parent/Guardian:

You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your

child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory

evidence of immunity and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs.

Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to

document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption.

Additionally, if a parent or guardian would like to give permission to the school to share their child’s immunization record with

Minnesota’s immunization information system, they may sign section 3 (optional).

For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection

(MIIC) at 651-201-5503 or 800-657-3970.

School Personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it.

Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space.

1st Dose

2nd Dose

3rd Dose

4th Dose

5th Dose

Type of Vaccine

DO NOT USE () or ()

Mo/Day/Yr

Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please

write the date in the shaded box.)

Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT)

• for children age 6 years and younger

5th dose not required if 4th dose was given

• final dose on or after age 4 years

on or after the 4th birthday

Tetanus and Diphtheria (Td)

• for children age 7 years and older

• 3 doses of Td required for children not up to date with DTaP,

DTP, or DT series above

Tetanus, Diphtheria and Pertussis (Tdap)

• for children in 7th - 12th grade

Polio (IPV, OPV)

• final dose on or after age 4 years

4th dose not required if 3rd dose was given

on or after the 4th birthday

Measles, Mumps, and Rubella (MMR)

• minimum age: on or after 1st birthday

Hepatitis B (hep B)

Varicella (chickenpox)

• minimum age: on or after 1st birthday

• vaccine or disease history required

Meningococcal (MCV, MPSV)

• for children in 7th - 12th grade

• booster given at age 16 years

Recommended

Human Papillomavirus (HPV)

Hepatitis A (hep A)

Influenza (annually for children 6 months and older)

Additional exemptions:

• Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the minimum

requirements of the law.

• Students in grades 7-12: A Tdap at age 11 years or later is required for students in grades 7-12. If a child received Tdap at age

7-10 years another dose is not needed at age 11-12 years. However, if it was only a Td, a Tdap dose at age 11-12 years is required.

• Students 11-15 years of age: A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the

alternative 2-dose schedule.

• Students 18 years of age or older: Do not need polio vaccine.

Developed by the Minnesota Department of Health - Immunization Program

(12/13)

Student Immunization Form

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