Name __________________________________________________________________________________________________________________________
Date of Birth ________________________________________ Phone (_______) _______________________
(TO BE COMPLETED BY NEW APPLICANTS ONLY)
The General Assembly of the State of Tennessee mandates that each public or private postsecondary institution in the state provide information concerning
measles, mumps, and rubella, varicella, and hepatitis B infections to all students matriculating for the rst time. Tennessee law requires that such students
complete and sign a waiver form provided by the institution that includes detailed information about these diseases. The required information below includes the
risk factors and dangers of these diseases as well as information on the availability and effectiveness of vaccines for persons who are at-risk for these diseases.
The information concerning each disease is from the Centers for Disease Control and the American College Health Association.
The law does not require that students receive vaccination for enrollment. Furthermore, the institution is not required by law to provide vaccination and/or
reimbursement for the vaccine.
Hepatitis B (HBV) Immunization
Hepatitis B (HBV) is a serious viral infection of the liver that can lead to chronic liver disease, cirrhosis, liver cancer, liver failure, and even death. The
disease is transmitted by blood and or body uids and many people will have no symptoms when they develop the disease. The primary risk factors
for Hepatitis B are sexual activity and injecting drug use. This disease is completely preventable. Hepatitis B vaccine is available to all age groups
to prevent Hepatitis B viral infection. A series of three (3) doses of vaccine are required for optimal protection. Missed doses may still be sought to
complete the series if only one or two have been acquired. The HBV vaccine has a record of safety and is believed to confer lifelong immunity in most
cases.
______ I hereby certify that I have read this information and I have had the entire series of the Hepatitis B vaccine.
______ I hereby certify that I have read this information and I have elected not to receive the Hepatitis B vaccine.
______ I hereby certify that I have read this information and I have elected to receive the Hepatitis B vaccine and/or I am in the process of receiving
the complete three dose series of the Hepatitis B vaccine.
Measles, Mumps, Rubella (MMR) and Varicella Immunizations
Measles causes fever, rash, cough, runny nose, and red, watery eyes. Complications can include ear infection, diarrhea, pneumonia, brain damage, and
death.
Mumps causes fever, headache, muscle aches, tiredness, loss of appetite, and swollen salivary glands. Complications can include swelling of the
testicles or ovaries, deafness, inammation of the brain and/or tissue covering the brain and spinal cord (encephalitis/meningitis), and, rarely, death.
Rubella causes fever, sore throat, rash, headache, and red, itchy eyes. If a woman gets rubella while she is pregnant, she could have a miscarriage or her
baby could be born with serious birth defects.
Varicella (chickenpox) causes blister-like rash, itching, fever, and tiredness. Complications can include severe skin infection, scars, pneumo nia, brain
damage, or death.
You can protect against these diseases with safe, effective vaccination.
______ I hereby certify that I have read this information and I have had the entire series of the MMR and Varicella vaccines.
______ I hereby certify that I have read this information and I have elected not to receive the MMR and Varicella vaccines.
______ I hereby certify that I have read this information and I have elected to receive the MMR and Varicella vaccines and/or I am in the process of
receiving the complete series of MMR and Varicella vaccines.
Date
(Parent/Guardian must authorize if student is under the age of 18)
For more information about these diseases and the vaccine schedules, please contact your local health care provider or consult the Center for Disease Control and
Prevention Web site at www.cdc.gov/health/default.htm
Parent: please complete this form for your minor child and email to admissions@southwest.tn.edu certifying that you have been informed about the
immunizations above.
Last First
Middle Initial
Month/Day/Year
IMMUNIZATION HEALTH HISTORY FORM
All students must complete top portion
0111601 NEW 18024 Southwest Tennessee Community College is an AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability or age in its program and activities.
The following person has been designated to handle inquiries regarding the non-discrimination policies: Executive Director of Human Resources and Afrmative Action, 737 Union Avenue, Memphis, TN 38103, (901) 333-5760.
Parent Name:
