Immunization Form

Bemidji State University
Student Center for Health and Counseling
Student Immunization Form
Student Name (Last, First, M.I.)
Date of Birth
Student Email
Student ID#
Phone
Minnesota Law (M.S. 135A.14) requires students enrolled in a public or private post-secondary school in Minnesota be immunized against
measles, mumps, rubella, diphtheria, and tetanus, allowing for certain specified exemptions (see below). This information will be
maintained as private information, available to school officials or state health officials who may need such information for public health
purposes. Unless you are exempt by law, as explained below, you are legally required to provide this information no later than
45 days after the start of your first term at BSU. Anyone who fails to submit the required information will not be allowed to register for
any subsequent classes. The Minnesota Department of Health and local health board are authorized by state law to inspect this
information.
Exemptions:
Graduated from a Minnesota high school after 1996.
Born before 1957
Enrolled in only one class, and NOT housed on campus.
Enrolled in extension or correspondence classes only.
Complete Part 3 for a conscientious exemption. This requires the signature of a notary.
If you are not exempt for any of the above listed reasons, complete Part 1. Enter the month, day, and year of your most recent “booster,”
shot for diphtheria and tetanus (Td) (This date must be within the last 10 years.) All doses of measles, mumps, and rubella vaccine must
have been received after the age of 12 months (1 year old). This information may be transferred from personal health records. We do not
require copies of these records. Please keep your health records for future use.
PART 1
Diphtheria/tetanus (Td)
Month/day/year:
Measles (rubeola, red measles)
Month/day/year:
Mumps
Month/day/year:
Rubella (German measles)
Month/day/year:
For the student: I certify that the above information is a true and accurate statement of the dates on which I received the
immunizations required by the Minnesota law.
Student’s signature___________________________________________________
Date_____________
Parent’s signature (If student is under 18 years of age)_________________________________Date______________
PART 2
MEDICAL EXEMPTION: The student named above does not have one or more of the required immunizations because he/she has
(check all that apply and fill in the appropriate blanks):
a medical problem that precludes the____________________________________________vaccine(s)
not been immunized because of a history of________________________________________________disease
shown laboratory evidence of immunity against____________________________________________________ .
Physician’s signature __________________________________________________Date____________________
PART 3
CONSCIENTOUS EXEMPTION: I hereby certify by notarization that immunization against _____________is contrary to my
conscientiously held beliefs.Student’s signature____________________________________Date_______________________
Parent’s signature (If student is under 18 years of age) ____________________________________ Date__________________
Subscribed and sworn before me on the ___________________________________ day of __________________ 20 ______
Signature of notary____________________________________________________________
Return form to: BSU Student Center for Health and Counseling, 1500 Birchmont Dr. NE #42, Bemidji MN 56601. Fax 218-755-2750
Email: [email protected]