8/13/2019 Immunization Form 2

1/2

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 ExemptionsMedical Exemption

Check one: Permanent exemption Temporary exemption Date to be released _______/_______/________

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

Side 1 of 2 (over) Revised April 2011

Social Security Number

MEASLES

MUMPS

RUBELLA

#1_____________________

month/day/year

#2_____________________

month/day/yearOR 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

8/13/2019 Immunization Form 2

2/2

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 DocumentationAll 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

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

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 readand 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 malabsorption syndromes

Chronic renal failure

Diabetes mellitus

HIV infection

Intestinal bypass or gastrectomy (stomach removal)

Leukemias

Low body weight (10% or more below ideal or BMI

of 18 or less)

Organ transplantation Silicosis

Immunosuppressed from 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

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)