Measles Immunity Report Form
Faculty and Staff Only

If you are a student, please fill out the Student Measles form

Human Resources Department, MS 9054, 516 High Street, Bellingham, WA 98225-5996 (360) 650-3774 FAX: (360) 650-2810
Name:
Western ID#
 Date of Birth:
       Considered immune if born BEFORE 1/1/57:
       No need to complete rest of this form
 

Submit ONE of the following as evidence of immunity to measles (rubeola):

1)  Paper documentation of two individual vaccinations against rubeola measles (not rubella)usually referred to as measles or MMR.  The doses must have been given (1) after January 1, 1968, (2) at least 30 days apart, and (3) on or after 12 months of age.  A copy of a medical provider vaccination record sheet or a copy of an official immunization card showing two individual administration dates for the rubeola vaccine is attached to this form.

-OR-

2)  Health Care Provider verification of two individual vaccinations against rubeola measles (not rubella), usually referred to as measles or MMR.  The doses must have been given (1) after January 1, 1968, (2) at least 30 days apart, and (3) on or after 12 months of age.  I'm unable to provide paper documentation of having received these vaccinations.  My Health Care Provider (physician or nurse) has signed below as verification that these vaccines for rubeola measles were administered on the dates indicated:
  #1 vaccination date:
month/day/year
#2 vaccination date:
month/day/year
I certify the accuracy of the vaccination dates above:
Health Care Providers Signature/Title/Date
  Name:
Telephone:
  Address (office stamp okay):

-OR-

3) History of disease (Health Care Provider verification required):
month/day/year
 
I certify that this individual had clinical rubeola measles disease:
Health Care Providers Signature/Title/Date
 
  Name:
Telephone:
   Address (office stamp okay):

-OR-

4)  Positive blood test for antibodies against rubeola (not rubella).  A copy of the lab test result is required.  I have attached a copy of my lab test result to this form.
 

  Return completed form to Human Resources Department, MS-9054, 516 High Street, Bellingham,WA 98225-5996 or FAX: (360) 650-2810

 
Approval by Director of Medical Services, WWU Student Health Center:
  Date:

(please sign here)