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Get Immunization Form Of Ulm

Cdc.gov/vaccines/hcp/vis/visstatements/mmr. html regarding vaccine-preventable disease and related vaccinations and have chosen not to be vaccinated. I understand that if I claim exemption I may be excluded from campus and from classes in the event of an outbreak of measles mumps rubella or meningitis until the outbreak is over or until I submit proof of immunization. If I am not 18 years of age or older my parent or legal guardian must also sign below. Student s Signature Parent or Legal Guardian if required RETURN THIS FORM TO 1140 University Avenue Monroe Louisiana 71209 Phone 318 342-5238 or fax 318 342-5239 ULM-8611 Rev. 01/14. The University of Louisiana at Monroe PROOF OF IMMUNIZATION COMPLIANCE Louisiana R.S. 17 170/170. 1/Schools of Higher Learning Please Print with Ink If information is not legible form will be rejected Name Last First Semester of Enrollment Middle Address Street City Date of Birth Gender M Telephone Number State F Zip Code Campus ID Number Email Address IMMUNIZATION REQUIREMENTS FOR ULM STUDENT THIS SECTION MUST BE COMPLETED BY A PHYSICAN OR HEALTH CARE PROVIDER We accept copies of immunization from Louisiana LINKS REQUIREMENTS OR MMR Measles Mumps Rubella Two doses required Date of 1st dose Date of 2nd dose MEASLES Two doses required or positive serology Date of IgG Serology Test Results AND MUMPS One dose required or positive serology Date TETANUS-DIPHTERIA One dose within past 10 years required TD or Tdap Date MENINGOCOCCAL One dose of required RUBELLA One dose required or positive serology Vaccine Type Signature of Health Care Provider Telephone REQUEST FOR IMMUNIZATION EXEMPTION. If you request an immunization exemption for medical or personal reasons or due to an inability to locate a specific vaccine please check the appropriate box and provide the reason. Medical physician s statement required Personal religious unable to locate records etc. Shortage of vaccine Reason I have reviewed information from the Center for Disease Control and Prevention s website at http //www. cdc*gov/vaccines/hcp/vis/visstatements/mmr. html regarding vaccine-preventable disease and related vaccinations and have chosen not to be vaccinated* I understand that if I claim exemption I may be excluded from campus and from classes in the event of an outbreak of measles mumps rubella or meningitis until the outbreak is over or until I submit proof of immunization* If I am not 18 years of age or older my parent or legal guardian must also sign below. Student s Signature Parent or Legal Guardian if required RETURN THIS FORM TO 1140 University Avenue Monroe Louisiana 71209 Phone 318 342-5238 or fax 318 342-5239 ULM-8611 Rev* 01/14.

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