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: _______________
_________________________
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)