500 University Ave, W, Minot, ND 58707 Fax 701-858-3997 Phone 701-858-3371 Student ID ________________ MMR 1 2 Comments: _______________ _________________________ OFFICE USE All information must be in English North Dakota State Board of Higher Education requires verification of two (2) measles, mumps, and rubella (MMR) Immunizations or immune titers for ALL students born after 12/31/56. (SEE EXEMPTIONS BELOW) SOURCES of immunization records may be obtained from your physician, public health clinic, high school, college, or military records. Name Birth Date Student ID Number ________ ______ ____ _____ ___/___/____ Last First Middle Former month day year Required signature by Health Care Provider _______________________________________________________ Date _____/_____/______ Health Care Provider name, title and address (please print) __________________________________________________________________ Immunization Exemptions Medical Exemption l cerLlfy LhaL lL would be harmful Lo Lhls sLudenL's healLh Lo be lmmunlzed agalnsL measles, mumps, and rubella. Check one: Permanent exemption Temporary exemption - Date to be released _______/_______/________ hyslclan's slgnaLure ______________________________________________________________________ uaLe _____/_____/______ hyslclan's address _______________________________________________________________________ I am only enrolling in distance education courses (online, correspondence, or an off-campus site). I adhere to a belief (philosophical or moral) that is opposed to immunizations. My birthdate is prior to January 1, 1957 SLudenL's SlgnaLure __________________________________________________________________________ uaLe _____/_____/______ Side 1 of 2 (over) Revised April 2011 Social Security Number MEASLES MUMPS RUBELLA #1 _____________________ month/day/year #2 _____________________ month/day/year OR MEASLES MUMPS RUBELLA Titer results and date ** _______________________________________________________ Month/day/year Titer results and date ** _______________________________________________________ Month/day/year Titer results and date ** _______________________________________________________ Month/day/year #1 _____________________ month/day/year #1 _____________________ month/day/year #2 _____________________ month/day/year #2 _____________________ month/day/year RECOMMENDED, but not required for admission to MSU Meningococcal Meningitis Vaccine Date: _____/_____/________ (within last 3-5 years) Tetanus Vaccine Date: _____/_____/________ (within last 10 years) ** ATTACH COPY OF TITER REPORT Return immunization document to: MSU Student Health Center 500 University Ave, W, Minot, ND 58707 Fax 701-858-3997 Phone 701-858-3371 Student ID ________________ MMR 1 2 Comments: _______________ _________________________ Name Birth Date Student ID Number ________ ______ ____ _____ ___/___/____ Last First Middle Former month day year Tuberculosis (TB) Screening Documentation All information must be in English Minot State University requires documentation of tuberculosis (TB) screening within six months prior to or after college entrance with a Mantoux skin test for those students meeting the following criteria: A. Check all that apply: Contact with a person known to have active tuberculosis Signs or symptoms of active TB such as chronic cough, bloody sputum, fever, night sweats or weight loss Health care worker Volunteer or employee of a nursing home, prison or other residential institution History of injection of illicit drugs Have been diagnosed with a chronic medical condition that may impair your immune system: Within the past five years have lived or traveled for >30 days ln a counLry where Lhere ls a hlgh lncldence" of 18. This includes many countries in Africa, Asia, Eastern Europe, Central and south America. (The United States has a low incidence of TB.) This list of countries is available on the MSU Student Health Servlce Web slLe under lmmunlzaLlons." None of the above apply. You do not need TB skin testing. B. If any of the above do apply, TB testing is requires. TB Skin Testing - call the MSU Student Health Center at (701) 858-3371 to schedule an appointment for testing. Provide documentation of TB testing done in the U.S. within the past 6 months by having a health care provider complete the section below (PPD Mantoux skin test read and documented millimeters of induration.) A chest x-ray performed in the U.S. will be required for anyone with a positive skin test. A negative chest x-ray is not substitute for a skin test. -Or Provide documentation of prior treatment of active TB disease. Cancer of the head and neck or lung Chronic malabsorptionsyndromes Chronic renal failure Diabetes mellitus HIV infection Intestinal bypass or gastrectomy (stomach removal) Leukemias, lymphoma or Podgkln's dlsease Low body weight (10% or more below ideal or BMI of 18 or less) Organ transplantation Silicosis Immunosuppressedfrom steroid use receiving equivalent of Prednisone 15 mg/day or more for 1 month or more C. Date Tuberculin PPD (Mantoux) given: ____/____/______ Date Tuberculin PPD (Mantous read: ____/____/______ month day year month day year Result: ___________________________ (record actual mm of induration, transverse diameter; if no induration, wrlLe 0") Interpretation (based on mm of duration as well as risk factors): Positive Negative Required signature by Health Care Provider ______________________________________________ Date _____/_____/______ Health Care Provider name, title and address (please print) _________________________________________________________ __________________________________________________________________________________________________________ Side 2 of 2 (over)