Certificate Of Immunization - Southwest Tennessee Community College Page 2
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2PART II
MMR AND VARICELLA
To be completed by medical doctor or health care provider
Check the appropriate box:
o Received two (2) doses of MMR vaccine
MMR #1 Mo/Yr______MMR#2 Mo/Yr______
o Received two (2) doses of Varicella vaccine
Varicella #1 Mo/Yr_____Varicella #2 Mo/Yr_____
o 1979-1998 TN high school grad needing second dose of MMR
MMR: Mo/Yr_______
o 1999-2016 TN high school grad needing second dose of Varicella
Varicella: Mo/Yr_______
o Medically contraindicated because of pregnancy, allergy to vaccine, etc. MMR____Varicella_____
Must list reasons:__________________________________________________________________
o Had disease as confirmed by my medical record. MMR: Mo/Yr_______Varicella: Mo/Yr______
o Laboratory confirmed immunity to the disease.
MMR Titer: Mo/Yr______ Varicella Titer:Mo/Yr______
MUST BE SIGNED BY A MEDICAL DOCTOR OR HEALTH CARE PROVIDER
Print name of physician ______________________________________________________________________
Address __________________________________________________________________________________
Office Telephone ____________________________________Office Fax Number _______________________
Physician’s Signature ___________________________________________________Date _________________
RETURN THIS FORM TO:
Southwest Tennessee Community College
P.O. Box 780 – Admissions Office
Memphis, TN 38101-0780
Southwest Tennessee Community College, a Tennessee Board of Regents institution, is an affirmative action/equal opportunity college. 0111083 REV 13007
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Parent category: Medical