Proof Of Immunization Compliance Form

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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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