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


 

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

 Request for a WAIVER from the 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

In support of this request, please answer the following questions:

1) State the reason for your request (personal, medical or religious):

2) Explain the rationale for your reason:

3) If you are unable to provide a Health Care Provider's signature (see below) in support of this request, please explain why:

4) State whether you believe you have ever received a measles (rubeola or MMR) immunization in the past or not:

5) Explain, in detail, why you are unwilling to get a rubeola titer (blood test for immunity) at this time:

I understand that immunity to measles (rubeola) is a condition of enrolling at WWU if I was born in 1957 or later.  I understand that it is recommended that I receive the vaccine or prove immunity with a positive rubeola titer (blood test for antibodies).  If my request for a waiver is approved, I understand that if I am exposed to measles, I may be prohibited from attending class or living on campus from the 5th through the 21st day after exposure or for 7 days after the rash appears.  I have been given an opportunity to ask questions about the vaccine, the titer and the policy concerning it.  All my questions have been answered to my satisfaction.  Due to medical, religious or personal reasons, i choose not to demonstrate adequate rubeola immunity.

 
  Student Signature: Date:
 
Health Care Provider Documentation (required for medical request):
I hereby certify that this student has legitimate medical reasons for inadequate rubeola immunity because (state reason):
    Health Care Provider's Signature/Title/Date  
    Name:  
    Address: (office stamp okay):  
   
   

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