Form Htse108fr - Immunization Record For Students Attending Post-Secondary Schools In Minnesota
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1Immunization Record for
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Students Attending Post-Secondary Schools in Minnesota
Student Name (Last, First, M.I.):
Date of Birth:
Tech ID:
Minnesota Law (M.S. 135A.14) requires that all students born after 1956 are vaccinated against diphtheria, tetanus, mea-
sles, mumps, and rubella, allowing for certain specified exemptions (see below). Any non-exempt student who fails to sub-
mit the required information within 45 days after first enrollment cannot remain enrolled. This form is designed to provide
the school with the information required by the law and will be available for review by the Minnesota Department of Health
and the local health agency.
ALL STUDENTS: Return this completed form to Minnesota State Mankato Health Services, CC21, Mankato, MN 56001
fax 507-389-5787; ph 507-389-6276; mnsu.edu/shs; healthservices@mnsu.edu
Check here if you were born before 1957 for the age exemption. You don’t have to complete the rest of this form.
All other students who are not age-exempt; Complete part 1, 2, 3, 4 or 5 below.
Part 1: Students graduating from a MINNESOTA high school within the last 10 years
I have previously met the MMR (measles, mumps, rubella) and Td (tetanus, diphtheria) requirements because I graduated from a
MINNESOTA high school within the last 10 years.
Name of MINNESOTA high school_________________________ City _____________________ Date of Graduation ____________
Student’s signature_____________________________________________________________ Date _________________________
Part 2: Transfer student from another MINNESOTA college in the past year
I am exempt from these requirements because my admission records indicate I have met the requirements as an enrolled student in
another post-secondary school in Minnesota. Name of previous Minnesota College:_______________________________________
Student’s signature ___________________________Date __________
Dates of enrollment: from____________ to ____________
Part 3: Students who graduated from an OUT OF STATE or MINNESOTA high school 10+ years ago
Mo/Day/Yr
Measles/mumps/rubella (MMR)
(most recent dose required at or after 12 months of age)
Tetanus/diphtheria (Td/Tdap)
(most recent dose required within past 10 years)
I certify that the above information is a true and accurate statement of the dates on which I was vaccinated.
Student’s signature_____________________________________________________________ Date _________________________
Part 4 and 5: Other exemption(s)
Part 4: Medical Exemption: The student named above lacks one or more of the required immunizations because he/she:
Check all that apply and fill in the appropriate blanks.
has a medical problem that precludes the __________________________________________________________ vaccine
has not been immunized because of a history of _____________________________________________________ disease
has laboratory evidence of immunity against ________________________________________________________ disease
Physician’s signature_____________________________________________________________ Date _______________________
Part 5: Conscientious Exemption: I hereby certify by notarization that immunization against
____________________________________________________ disease is contrary to my conscientiously held beliefs.
Student’s signature_____________________________________________________________ Date _________________________
Subscribed and sworn to before me this _________ day of ___________________________, 20_______.
NOTARY SIGNATURE _________________________________________________________________
Adapted from:
* Please make a copy of this form. Your completed form
Immunization Program
will NOT be accessible for future reference or duplication.
800-657-3970, 651-201-5503
IC#140-0473 HE# 01477-03 (MDH, 2/06)
HTSE108FR_06/15
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