<%@ Page Language="vb" EnableViewState="true" EnableSessionState="true" CodeBehind="loadForm.vb" Inherits="eSignProcess.loadForm"%> Measles Immunity Report for Student


 

Measles Immunity Report Student
FRM-U1300.01D
Student Health Center
516 High Street Bellingham, WA 98225-9132
360.650.3400 FAX 360.650.3883

 MEASLES IMMUNITY Registration Requirement
Student Information - Please Print or Type (if we can't identify you, we can't help you)
   

Student#
Name
Current Mailing Address
   
Current Email Address  
Date of Birth

Area Code & Phone

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 mealses (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 o the dates indicated:
 

#1 vaccination date:

 #2 vaccination date:
    month/day/year   month/day/year
    I certify the accuracy of the vaccination dates above:
     
    Health Care Provider's Signature/Title/Date  
   

Name:

 Phone
    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 Provider's Signature/Title/Date  
    Name: Phone
    Address: (office stamp okay):  
   
   

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

Student Health Center, WWU 516 High Street Bellingham, WA 98225-9132
(360) 650-3400  FAX (360) 650-3883
Student.Health@wwu.edu  www.ac.wwu.edu/~chw/SHCmeasles.html