Immunization Let

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Immunization Record for
Students Attending Post-Secondary Schools in Minnesota Student Name (Last, First, M.I.) | Date of Birth | Student ID Number | Date of Enrollment (Mo/Yr) 10/2015 |
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.
All students: Return this completed form to _______________________________________ by ______________. Check here if you were born before 1957 for the age exemption. You don’t have to complete the rest of this form.
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 | 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. 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…...

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