Louisiana Tech University Medical History (Page 2 of 3) in pdf

PROOF OF IMMUNIZATION COMPLIANCE

UNIVERSITY REQUIRED IMMUNIZATIONS:

Physician or Other Health Care Provider Verification or Universal Certificate of Immunizations attached:

MMR (Measles, mumps, rubella – 2 doses required)

Td or Tdap

First dose: ____________________

Td: ________________

(Date)

Serologic Test: ___________________

(Date within 10yrs)

(Date)

Second dose: __________________

(Date)

Result: __________________________

Tdap: _______________

OR ____________ Born before 1957

(Date within 10yrs)

Meningococcal Vaccine (One dose must be received on or after 16

birthday)

Vaccine Type: _____________________________________

Date: ________________________________________

_______________________________________

_______________

OFFICE STAMP REQUIRED

(Signature of Physician or other health care provider)

(Date)

UNIVERSITY RECOMMENDED IMMUNIZATIONS:

Physician or Other Health Care Provider Verification:

Hepatitis B Vaccine

Varicella (chicken pox)

First dose: ___________

First dose: ____________

Disease: _________________

(Date)

Second dose: _________

Second dose: __________

Serologic Test: _____________ Result: ____________

(Date)

Third dose: __________

Varicella (either a history of chicken pox, a positive Varicella antibody or two doses of a

(Date)

vaccine given at least one month apart if immunized after 13 years, meet the requirement.

Please read the following information carefully:

Louisiana Law (R.S. 17:170/R.S. 17:170.1/Schools of Higher Learning)

requires all students entering Louisiana Tech University to be

immunized for the following: Measles, Mumps, Rubella (2 doses) for those born on or after January 1, 1957; Tetanus-Diphtheria (within the past 10

years); and against Meningococcal disease (Meningitis). The following guidelines presented are for the purpose of implementing the requirements of

Louisiana R.S. 17:170.1, and of meeting the established recommendations for control of vaccine-preventable diseases as recommended by the

American Academy of Pediatrics (AAP); the Advisory Committee on Immunization Practices to the United States Public Health Service (ACIP); and

the American College Health Association (ACHA). Students not meeting these requirements will be prevented from registering for subsequent

quarters.

Louisiana Tech University adheres to the equal opportunity provisions of federal and civil rights laws, and does not discriminate on the basis of race,

color, national origin, religion, age, sex, sexual orientation, marital status or disability.

Request for Exemption – MMR and/or Meningitis

____Medical Reasons (Physician’s statement in space provided)

____Personal Reasons

____________________________________________________________________________________________________________

I fully understand that if I claim exemption for medical or personal reasons, I may be excluded from campus and 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.

________________________________

________

_____________________________________

_______

Student Signature

Date

Physician Signature for Medical Exemption

Date

Revised: 8/13

Louisiana Tech University Medical History Page 2

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