Student Immunization Form (Page 2 of 2) in pdf

Student Name

_______________________________________________

Instructions, please complete:

Box 1 to certify the child’s immunization status

Box 2 to file an exemption (medical or concientious)

Box 3 to provide consent to share immunization information (optional)

1. Certify Immunization Status.

Complete A or B to indicate child’s immunization status.

A. Received all required immunizations:

B. Will complete required immunizations within

the next 8 months:

I certify that this student has received all immunizations

required by law.

I certify that this student has received at least one dose

of vaccine for diphtheria, tetanus, and pertussis (if

age-appropriate), polio, hepatitis B, varicella, measles,

mumps, and rubella and will complete his/her diphthe-

Signature of Parent / Guardian OR Physician / Public

ria, tetanus, pertussis, hepatitis B, and/or polio vaccine

Clinic

series within the next 8 months.

The dates on which the remaining doses are to be given are:

_______________ Date

Signature of Physician / Public Clinic

_______________ Date

2. Exemptions to School Immunization Law.

Complete A and/or B to indicate type of exemption.

A. Medical exemption:

B. Conscientious exemption:

No student is required to receive an immunization if they

No student is required to have an immunization that

have a medical contraindication, history of disease, or

is contrary to the conscientiously held beliefs of his/

laboratory evidence of immunity. For a student to receive

her parent or guardian. However, not following vaccine

a medical exemption, a physician, nurse practitioner, or

recommendations may endanger the health or life of the

physician assistant must sign this statement:

student or others they come in contact with. In a disease

outbreak schools may exclude children who are not vac-

I certify the immunization(s) listed below are

cinated in order to protect them and others. To receive

contraindicated for medical reasons, laboratory evidence

an exemption to vaccination, a parent or legal guardian

of immunity, or that adequate immunity exists due to

must complete and sign the following statement and

a history of disease that was laboratory confirmed

have it notarized:

(for varicella disease see * below). List exempted

immunization(s):

I certify by notarization that it is contrary to my conscien-

tiously held beliefs for my child to receive the following

vaccine(s):

Signature of physician/nurse practitioner/physician assistant

_______________ Date

Signature of parent or legal guardian

*History of varicella disease only. In the case of varicella

disease, it was medically diagnosed or adequately

_______________ Date

described to me by the parent to indicate past varicella

Subscribed and sworn to before me this:

infection in ___________ (year)

_______ day of ______________________ 20______

Signature of physician/nurse practitioner/physician

assistant

Signature of notary

(If disease occured before September 2010, a parent can sign.)

3. Parental/Guardian Consent to Share Immunization Information (optional):

Your child’s school is asking your permission to share your child’s immunization documentation with MIIC, Minnesota’s

immunization information system, to help better protect students from disease and allow easier access for you to retrieve your

child’s immunization record. You are not required to sign this consent; it is voluntary. In addition, all the information you provide is

legally classified as private data and can only be released to those legally authorized to receive it under Minnesota law.

I agree to allow school personnel to share my student’s immunization documentation with Minnesota’s immunization information

system:

Signature of parent or legal guardian

Date

Developed by the Minnesota Department of Health - Immunization Program

(12/13)

Student Immunization Form Page 2

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