Immunization Record For Students Attending Post-Secondary Schools printable pdf download

IMMUNIZATION RECORD FOR

STUDENTS ATTENDING POST-SECONDARY

SCHOOLS IN MINNESOTA

Student Name

Date of Birth:

Mustang ID Number:

Enrollment Date (Mo/Yr):

(Last, First, MI):

* Please make a copy of this form. Your completed form will NOT be accessible for future release or duplication.

Minnesota Law (M.S. 135A.14) requires proof that all students born after 1956 are vaccinated against diphtheria, tetanus, measles, mumps, and rubella,

allowing for certain specified exemptions (see below). Any non-exempt student who fails to submit the required information within 45 days after the 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 SMSU Health Services, BA 158, 1501 State Street, Marshall, MN 56258

Fax: (507) 537-7259, Phone: (507) 537-7202,

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 the section below that applies to you.

PART 1:

Students graduating from a Minnesota high school in 1997 or later

I have previously met the MMR (measles, mumps, rubella) and Td (tetanus, diphtheria) requirements because I graduated from a

Minnesota high school in 1997 or later.

Name of high school ___________________________________ City: _________________________ Date of graduation: ________________

Student’s Signature ___________________________________________________________________ Date _____________________________

PART 2:

Transfer student from another Minnesota college

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 enrolled from _____________ to _____________

PART 3:

Students who graduated from a Minnesota high school before 1997 or students from out of state

Mo/Day/Yr (most recent date please)

Tetanus/diphtheria (Td) -

at least one dose required within past 10 years

Measles/Mumps/Rubella (MMR) -

at least one dose required given > 12 months of age

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 & 5:

Other exemption(s): *Note special signature requirements

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__________________________________________________________________________________________________

* Please make a copy of this form.

Your completed form will NOT be accessible for future release or duplication.

Telephone (507) 537-7202 • (507) 537-7259 • 1501 State Street, Marshall, MN 56258 •

8/14

A member of the Minnesota State Colleges & Universities System. SMSU is an equal opportunity educator & employer. ADA Accessible.

Immunization Record For Students Attending Post-Secondary Schools

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