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Please PrintName:

PROOF OF' IMMUNIZATION COMPLIANCELouisiana R.S. 17:170/Schools of Higher Learning

Semester of Enrollment :(Fin0 (M.r.)(l-ast)

Email:(State) (Zip Code)

Date of Birth: lD Number: Telephone: (_)

IMMUNIZATION REQUIREMENTS FOR LSU STUDENTS

REOUIREMENTS:

MMR (Measles, Mumps, Rubella)(Two Doses Required)Date of 1tt dose:Date of 2"d dose:

AND

TETANUS-DIPHTHERIA(One Dose Required Within 10 years)Date:

AND

MENINGITIS(one Dose of Menactra Anytime or a Dose of Menomune within the past year)DatefVaccine type:

MEASLES(Two Doses Required)Date of 1't dose:Date of 2nd dose:

MUMPS(At least One Dose Required)Date:

RUBELLA(At least One Dose Required)

Date:

Signature of Heahh Care Provider Datei1,,,711,,r i.ii--r:-ii.''1 ;'ii:5i i-. i..

,:-i) 1.1 r-luiv 1llii {::!*"Address r.:ar,,rifi{it3it, i i1 ,/i"14:j3 Telephone

Request for Immunization Exemption: If you request an immunization exemption for medical or personal reasons or due toan inability to locate a specific vaccine, please check the appropriate box and provide the requested information.

n Medical (physician's statement required) n Personal (state reason in space below) n Shortage (unable to locate vaccine)

I have received and reviewed information from the Center for Disease Control and Prevention's (CDC's) website athttp://wrvw.cdc.govinip/publicationsA/lsldefault.htm regarding vaccine-preventable diseases and related vaccinations and havechosen not to be vaccinated. I understand that if I claim exemption for personal or medical reasons, I may be excluded from campusand from classes in the event of an outbreak of measles, mumps, or rubella until the outbreak is over or until I submit proof ofimmunization. If I am not 18 years of age, my parent or legal guardian must sign below.

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Student's Signature Date Parent or Legal Guardian, ifrequired Date

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Please PrintName:

PROOF OF IMMUNIZATION COMPLIANCELouisiana R.S. l7:170/Schools of Higher Learning

Semester of Enrollment:(Firs0 (M.r.)

Email:(State) (Zip Code)

ID Number: Telephone: (_)

IMMUNIZATION REQUIREMENTS FOR LSU STUDENTS

(hst)

Address:

Date of Birth:

Y R

REOUIREMENTS:

MMR (Measles, Mumps, Rubella)(Two Doses Required)Date of lttdose:Date of 2nd dose:

TETANUS.DIPIITHERIA(One Dose Required Within 10 years)Date:

ANI)

MENINGITIS(one Dose of Menactra Anytime or a Dose of Menomune within the past year)Date: _Vaccine type:

or MEASLES(Two Doses Required)Date of 1't dose:Date of 2nd dose:

MUMPS(At least One Dose Required)Date:ANI)

RUBELLA(At least One Dose Required)

Date:

Signature of Health Care Providert.., ri'.iI it',t, i I r..';J i ;l 1 r i *s i"... i'. . i", -r: l I r 11,1 ,r I i-Xl 1,1+. f ' (_)

Address '.,r,,.ill.r;,'iI ,:. it4.ll:{

Request for Immunization Exemptioni If you request an immunization exemption for medical or personal reasons or due toan inability to locate a specific vaccine, please check the appropriate box and provide the requested information.

n Medical (physician's statement required) r Personal (state reason in space below) I Shortage (unable to locate vaccine)

I have received and reviewed information from the Center for Disease Control and Prevention's (CDC's) website athttp://wrvw.cdc.gov/nipipublicationsA/lSidefault.htm regarding vaccine-preventable diseases and related vaccinations and havechosen not to be vaccinated. I understand that if I claim exemption for personal or medical reasons, I may be excluded from campusand from classes in the event of an outbreak of measles, mumps, or rubella until the outbreak is over or until I submit proof ofimmunization. If I am not l8 years of age, my parent or legal guardian must sign below.

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Student's Signatttre Dote Parent or Legal Guardian, if required Date

Name: lD Number:

(MANDATORY _ NO EXEMPTTONS)

rr" stuotnt Heatth Center is evaluating all entering students for exposure to tuberculosis (TB). please review and complete theinformationb"lo*"'".Ifyouhaveanyquestions,pleasecontacttheSrudentHea1thc""ffi.rryUulrdv9.1rIyques[lUIrs,Pr€

PAST HISTORY1. Have you ever lived in, or traveled to (within the past 5 years) any country in the following

areas of the world?Afi"ica, Asia, Caribbean nations, Central America (including Mexico), Eastern Europe,France, India and other Indian subcontinent Nations, Midclle East, b,ortugal,south America, south pacific (except Australiet and New zealand), o, spirn

Z. Do you have a history of alcoholism or intravenous drug use?

Do you have cancer, leukemia, kidney disease, diabetes, AIDS/HIY, or takeimmunosuppressive medication such as prednisone?

Have you been in close contact with someone with TB?

Have you resided, worked or volunteered in a prison, homeless shelter, hospital,nursing home, or other long-tern treatment faCitityt

IMPORTANT: If you have answered 6'YE!"_to any of these questions, you are required to have a ppD skin test within theDast vear before you can pay University fees. You can obtain the PPD skin test from your physician or public health ;iinic.

NOTE To HEALTH CARE PROVIDERS: Please record the size of the induration in millimeters. A result recorded as "positive,,or "Negative" will not be accepted. If there is no reaction, pt.uo re.ord as "0 mm". Students who have had a BCG vaccine arestill required to have a PPD skin test. A chest x-ray is required, if the tuberculin skin test is positive. pLEASE FOLLOWTHE CENTERS FOR DISEASE CONTROL AI.{D PREVENTION (CDC) GUIDELINES FOR THE TREATMENT OFLATENT TUBERCULOSIS TNFECTTON (LTBr)_ SEE WWW.CpC.iOV.

YES NO

-1 .

4.

5.

Date PPD Applied:

Date of Chesr X-ray:

Date PPD Read: Size of Induration:

AbnormalResult: Normal

Name of Medication: Date Initiated:

Health Care Provider's Name:

Health Care Provider's Signature:

**REMEMBER! You will not be etigible to pay University fees until all immunization records are in complianceor the exemption is signed.

LSU Student Health CenterImmunizationsBaton Rouge, LA 70803

Telephone (225) 578-0593Fax (225) 578-5282www.lsu.edu/shc

RETURN THIS FORM TO:

Revised 04/07

Name: ID Number:

TUBERCULOSIS OUESTIOI{NAIRT

(MANDATORY - NO EXEMPTTONS)

fte SruAent Health Center is evaluating all entering students for exposure to tuberculosis (TB). Please review and complete theinformation below even if vou have received a BCG (TB) vaccination in the nast. If you have any questions, please contact theStudent Health Center at (225) 578-0593.

PAST HISTORY1. Have you ever lived in, or traveled to (within the past 5 years) any country in the following

areas of the world?Afi"ica, Asia, Caribbean nations, Central America (including Mexico), Eastern Europe,France, India and other Indian Subcontinent Nations, Middle East, Porrugal,South America, South Pacffic (except Australia and New Zealand), or Spain

2. Do you have a history of alcoholism or intravenous drug use?

3. Do you have cancer, leukemia, kidney disease, diabetes, AIDS/HIV, or takeimmunosuppressive medication such as prednisone?

4. Have you been in close contact with someone with TB?

5. Have you resided, worked or volunteered in a prison, homeless shelter, hospital,nursing home, or other long-term treatment facility?

YES NO

IMPORTANT: If you have answered *YES' to any of these questions, you are required to have a PPD skin test within thepast vear before you can pay Universify fees. You can obtain the PPD skin test from your physician or public health clinic.

NOTE TO HEALTH CARE PROVIDERS: Please record the size of the induration in millimeters. A result recorded as "Positive"or "Negative" will not be accepted. If there is no reac,tion, please record as "0 mm". Students who have had a BCG vaccine arestill required to have a PPD skin test. A chest x-ray is required, if the tuberculin skin test is positive. PLEASE FOLLOWTHE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) GUIDELINES FOR THE TREATMENT OFLATENT TUBERCULOSN INFECTTON (LTBI) - SEE WWW.CDC.GOV.

Dare PPD Applied: Date PPD Read:

Date of Chest X-ray:

Size of Induration:

AbnormalResult: Normal

Name of Medication: Date Initiated:

Health Care Provider's Name:

Health Care Provider's Signature:

**REMEMBER! You will not be eligible to pay University fees until all immunization records are in complianceor the exemption is signed.

RETURN THIS FORM TO: LSU Student Health Center Telephone (225) 578-0593Immunizations Fax (225) 578-5282

Baton Rouge, LA 70803 www.lsu.edu/shc

Revised 04/07