PROOF OF IMMUNIZATION COMPLIANCE
Louisiana R.S. 17:170/Schools of Higher Learning
Phone: (225) 771-4770 Fax: (225) 771-6225
P.O. Box 10174 Helen Barron Drive Baton Rouge, LA 70813
Name:_____________________________________________ Semester of Enrollment:___________________
Please Print (Last)
(First)
(M.I.)
Address: _________________________________________________ Email:___________________________
(Street/P.O. Box)
(City)
(State)
(Zip Code)
Date of Birth:_______________ SU ID Number: S0-_ _ _-_ _ _ _ Telephone: (_____)___________________
THIS MUST BE COMPLETED BY A PHYSICIAN OR HEALTH CARE PROVIDER – NO ATTACHMENTS ACCEPTED
Write date of lab test if
Date
Date
Date
Date
Date
immune and provide copy of
Vaccine
Received
Received
Received
Received
Received
results. If history of varicella
mm/dd/yy
mm/dd/yy
mm/dd/yy
mm/dd/yy
mm/dd/yy
write date and “disease”.
Required Immunizations
MMR – Measles Mumps Rubella:
Two doses required
(Two doses of MMR at least 28 days apart
after 12 months of age. Those born before
1957 are exempt.)
Tetanus – One of below doses.
Specify Vaccine Type:
□
TD
□
TDAP
(Must be within the last 10 years)
Meningitis –
ACYW-135 –
One of
below doses. Specify Type:
□
Menactra
□
Menveo
(Students 21 or under are required
to have a dose at 16 or older. If over
21 dose can be given at any time.)
□
Menomune
(Must be within the last 12 months)
Other Immunizations (Not Required)
□
Specify
Polio OPV
□
Vaccine: Polio IPV
Hib
Hepatitis A
Hepatitis B
Influenza
Pneumococcal
Rotavirus
Varicella
______________________________________________________________________
__________________________________
Signature of Health Care Provider
Date
________________________________________________________________________________________
(________) _________________________________
Address
Telephone
Request for Immunization Exemption:
If you request an immunization exemption for medical or personal reasons or due
to an inability to locate a specific vaccine, please check the appropriate box and provide the requested information.
□ Medical (physician’s statement required)
□ Personal (state reason in space below)
□ Shortage (unable to locate vaccine)
___________________________________________________________________
I have received and reviewed information from the Center for Disease Control and Prevention’s (CDC’s) website at
regarding vaccine preventable diseases and related vaccinations and have chosen not to be vaccinated. I understand that if I claim exemption for personal or medical reasons, I
may be excluded from campus and from classes in the event of an outbreak of measles, mumps, rubella, or meningitis until the outbreak is over or until I submit proof of
immunization. If I am not 18 years of age, my parent or legal guardian must also sign below.
____________________________________
______________
__________________________________
______________
Student’s Signature
Date
Parent or Legal Guardian, if required
Date
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