Admissions: Immunization Waiver Form (18 and under)

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Immunization Health History Form

Enrollment Services | Phone: 865-694-6400 | Fax: 865-539-7660

This form should only be filled out by a parent of a student that is under 18 years of age. This form is not required for students 18 years or older.

Student PNumber (provided to you by the student):

Student Legal First Name:

Student Legal Last Name:

Each public or private postsecondary institution in the state must provide information concerning measles, mumps, rubella, varicella, and hepatitis B infections to all students matriculating for the first time. Tennessee law requires that such students complete and sign this waiver form provided by the institution, which includes detailed information about these diseases. The required information below includes the risk factors and dangers of these diseases as well as information on the availability and effectiveness of vaccines for persons who are at-risk for these diseases. The information concerning each disease is from the Centers for Disease Control and the American College Health Association.

The law does not require that students receive vaccination for enrollment. Furthermore, the institution is not required by law to provide vaccination and/or reimbursement for the vaccine. A student may be exempted from immunization requirements if vaccination conflicts with the religious tenets and practices of the student or if a licensed physician determines that the risk of harm from the vaccine outweighs the potential benefit.

Hepatitis B (HBV) Immunization

Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and even death. The disease is transmitted by blood and or body fluids and many people will have no symptoms when they develop the disease. The primary risk factors for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable. Hepatitis B vaccine is available to all age groups to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most cases.

You are required to select one of the following statements:

I hereby certify that I have read this information and I have had the entire series of the Hepatitis B vaccine.

I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine.

I hereby certify that I have read this information and I have elected to receive the Hepatitis B vaccine and/or I am in the process of receiving the complete three dose series of the Hepatitis B vaccine.

Measles, Mumps, Rubella (MMR) and Varicella Immunizations

Measels, causes fever, rash, cough, runny nose, and red, watery eyes. Complications can include ear infection, diarrhea, pneumonia, brain damage, and death.

Mumps causes fever, headache, muscle aches, tiredness, loss of appetite, and swollen salivary glands. Complications can include swelling of the testicles or ovaries, deafness, inflammation of the brain and/or tissue covering the brain and spinal cord (encephalitis/meningitis), and, rarely, death.

Rubella causes fever, sore throat, rash, headache, and red, itchy eyes. If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects.

Varicella (chickenpox) causes blister-like rash, itching, fever, and tiredness. Complications can include severe skin infection, scars, pneumonia, brain damage, or death.

You can protect against these diseases with safe, effective vaccination.

You are required to select one of the following statements:

I hereby certify that I have read this information and I have had the entire series of the MMR and Varicella vaccines.

I hereby certify that I have read this information and I have elected not to receive the MMR and Varicella vaccines.

I hereby certify that I have read this information and I have elected to receive the MMR and Varicella vaccines and/or I am in the process of receiving the complete series of MMR and Varicella vaccines.

Parent/Legal Guardian Signature (This form must be electronically signed by a parent - NOT the student.)

*Grandparents, foster parents and legal guardians are not considered parents on this form unless they have legally adopted the student.

Parent First Name:

e.g. xxxxxxxxxxxxxxxxxxx

Parent Last Name:

e.g. xxxxxxxxxxxxxxxxxxx

Parent PIN (Last four digits of parent social security number and four digit year of birth. Example: If parent SSN is 123-45-6789 and date of birth is 4/1/1969, the parent PIN would be 67891969):

e.g. 9999999999

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