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

Immunization Record for

Students Attending Post-Secondary Schools in Minnesota

Students: Return this completed form to the post-secondary school you will be attending before enrolling.

All Students: Please return this completed form to LSC Student Services. If the form is not recieved, a hold will be

placed on your record that will prevent you from registering for classes for your second semester.

Student Name (Last, First, M.I.)

Date of Birth

Student ID Number

Date of Enrollment (Mo/Yr)

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 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.

Check here if you were born before 1957 for the age exemption. If you were, you don’t have to complete the rest of this

form; however you still must return this form to your school.

All other students who are not age-exempt: Complete parts 1, 2, 3, and/or 4 below.

(GED or homeschool grads fill out part 3 and/or 4 below)

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) or Tdap (tetanus, diphtheria,

pertussis) requirements because I graduated from a Minnesota high school in 1997 or later.

Student’s signature ___________________________________________________________ Date ___________________

Name of high school:

City:

Date of graduation:

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.

Student’s signature___________________________________________________________ Date ____________________

Name of previous Minnesota college:

Dates of enrollment: from ____________ to ____________

Part 3: Students who graduated from a Minnesota high school before 1997 or students from out of state

Mo/Day/Yr Mo/Day/Yr

Tetanus/diphtheria (Td or Tdap) (at least one dose required within past 10 years)

Measles/mumps/rubella (MMR) (at least one dose required at or after 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: Other exemption(s): A physician’s signature is required for a medical exemption, and a notary’s signature is required

for a conscientious exemption

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 ____________________

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____.

Signature of notary ___________________________________________________________________________________

Immunization Program

651-201-5503 or 1-800-657-3970

(7/14)

Immunization Record For Students Attending Post-Secondary Schools In Minnesota

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