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Immunization Records Request


Timertimer
* = required field

Immunization Record for Students

Attending Post-Secondary Options at Minnesota State Community and Technical College


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

Student Name: (First, M.I., Last)
Date of Birth:
Student ID Number:
Date of Enrollment:
* * * *
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 Minnesota State Community and Technical College.

All other students who are not age-exempt: Complete parts 1, 2, 3 and/or 4 below.
   PART 1: Students graduating from a Minnesota high school in 1997 or later.
Name of high school:

City:

Date of graduation:
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.         
   PART 2: Transfer student from another Minnesota college Name of previous Minnesota college:
Date of enrollment: from/to
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.
     
   PART 3: Student 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 on 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.
   PART 4: Other exemptions(s): A physician's signature is required for a medical exemption, and a notary's signature is required for a conscientious exemption  (if you are choosing this option, please print this form and submit after obtaining required signatures)
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 medial problem that precludes the _____________________________________vaccine.
   has not been immunized because of a history of __________________________________disease.
   has a 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: ____________________________________________________

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