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STUDENT IMMUNIZATION RECORD FORM

Name:_________________________  Social Security Number:____________________
Date of Birth:________________

REQUIRED: Measles (Rubeola) Immunity

  1. TWO dates of Measles Immunizations: (1)__________  (2)__________
    Both must be given after 1967 AND on or after the first birthday, with at least 30 days between doses.
        OR
  2. Date of Measles Titer__________ Results: PLEASE ATTACH COMPLETE LAB REPORT.
        OR
  3. Date physician diagnosed measles disease__________
    AND Signature of the diagnosing physician.____________________________


REQUIRED: Rubella (German Measles) Immunity

  1. Date of one Rubella Immunizations (1)__________
    Must be on or after the first birthday
        OR
  2. Date of Rubella Titer__________ Results: PLEASE ATTACH COMPLETE LAB REPORT.
    Physician diagnosis is not acceptable.


REQUIRED: Mumps Immunity

  1. Date of one Mumps Immunization: (1)__________
    Must on or after the first birthday
        OR
  2. Date of Mumps Titer__________ Results: PLEASE ATTACH COMPLETE LAB REPORT.
        OR
  3. Date physician diagnosed mumps disease__________
    AND signature of the diagnosing physician.____________________________


PLEASE NOTE: MMR vaccine is recommended to provide protection against all three vaccine preventable diseases: measles, mumps, and rubella.

X__________________________________     ________________
Signature of Health Practitioner     Date
MUST BE R.N., M.D., P.A. OR N.P.

EXEMPTION:

This student should be granted an exemption for medical reasons.
This exemption is ___ permanent
___ temporary, until _______________
please provide date

X__________________________________     ________________
Signature of Health Practitioner     Date
MUST BE R.N., M.D., P.A. OR N.P.