Immunization Record for
Students Attending Post-Secondary Schools in Minnesota
Student Name (Last, First, M.I.):
Date of Birth:
Star ID/Student ID:
Date of Enrollment (Mo/Yr):
Minnesota Law (M.S. 135A.14) requires proof that all students born after 1956 are vaccinated against diphtheria,
tetanus, measles, mumps, and rubella, allowing for certain specified exemptions (see below). This form is designed
to provide the school with the information required by the law and will be available for review by the Minnesota
Department of Health and the local health agency.
Check here if you were born before 1957 for the age exemption. You don’t have to complete the rest of this
All other students who are not age-exempt:
Complete parts 1, 2, 3, and/or 4 below.
Part 1:
Students graduating from a Minnesota high school in 1997 or later
I have previously met the MMR (measles, mumps, rubella) and Td (tetanus, diphtheria) requirements because I graduated from a
Minnesota high school in 1997 or later.
Student’s signature ___________________________________________________________ Date ____________________
Name of high school:
Date of graduation:
Part 2:
Transfer students from another Minnesota college
I am exempt from these requirements because my admission records indicate I have met the requirements as an enrolled student in
another post-secondary school in Minnesota. Student’s signature___________________________________Date_________________
Tetanus/diphtheria (Td)
(at least one dose required
within past 10 years
I certify that the above information is a true and accurate statement of the dates on which I was vaccinated.
Student’s signature __________________________________________________________ Date ______________________
Part 4:
Other exemption(s)
Medical Exemption: The student named above lacks one or more of the required immunizations because he/she:
(Check all that
apply and fill in the appropriate blanks.)
nst _________________________________________________ disease
Physician’s signature _________________________________________________________ Date ______________________
Conscientious Exemption: I hereby certify by notarization that immunization against
_________________________________________________________________ disease is contrary to my conscientiously held beliefs.
Student’s signature __________________________________________________________ Date ______________________
Subscribed and sworn to before me this ____ day of __________________, 20__.
Signature of notary ________________________________________________________
East Grand Forks, MN Thief River Falls, MN
2022 Central Ave NE 1101 Highway One E
East Grand Forks, MN 56721 Thief River Falls, MN 56701
Local: 218.793.2800 Local: 218.683.8
Toll-free: 1.800.959.6282 Toll-free: 1.800.959.6282
Immunization Program
800-657-3970, 651-201-5503
IC#140-0473 HE# 01477-03 (MDH,
2/6/2020 bgh
Fax: 218. 793.2843 Fax: .218.683.8980
TDD: 218.793.2801 TDD: 218.683.8801
Northland Community and Technical College is an affirmative action, equal opportunity employer and educator.
This document is available in alternative formats to individuals with disabilities, consumers with hearing or speech disabilities may contact us via their preferred Telecommunications Relay
Service by dialing 711 (toll-free nationwide).
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For college students
Here’s what you need to know about
the College Immunization Law
When you enroll in college in Minnesota, you
may need to show that you’ve been vaccinated
against five major vaccine-preventable diseases:
measles, mumps, rubella, tetanus, and diphtheria.
The Minnesota College Immunization Law
applies to anyone who was born after 1956.
However, students who graduated from a
Minnesota high school in 1997 or later are exempt
from these requirements under the law (because
they will already have met them as a high school
student), although some colleges may require
proof of immunizations from these students too.
Minnesota laws also require post-secondary
schools to provide students with information on
the transmission, treatment, and prevention of
hepatitis A, B, C, and meningococcal disease.
But adults don’t get these diseases –
do they?
At one time, getting the mumps or the measles
was a normal part of growing up. Then, during the
1960s, effective vaccines became available and
we all but eliminated these “childhood” diseases.
But today, while the incidence of disease has
dropped dramatically in young children, there are
still occasional outbreaks of these diseases and
they more often than not affect young adults. It’s
important, too, for adults of all ages to get
“boosted” for tetanus and diphtheria every 10
years throughout their lifetime.
But these diseases aren’t very
serious are they?
Measles is the most serious of these five diseases.
It can cause life-threatening pneumonia and brain
inflammation, middle-ear infections, severe
diarrhea, and sometimes convulsions. The risk of
death from measles is known to be higher in
adults than in children.
Mumps can cause hearing loss. And, about one
out of four teenage or adult men who have
Minnesota Department of Health Immunization Program
infections. Anyone can get meningococcal disease.
College freshmen who live in dormitories or close
living quarters have an increased risk of getting
meningococcal disease.
So, what do I have to do?
Under Minnesota law, you have to submit a complete
immunization record to your college or meet one of
the legal exemptions (see below). You might be
automatically exempt if you graduated from high
school in Minnesota since 1997 or you previously
were enrolled in another college in Minnesota (in
which case your former college record should indicate
that you met the law’s requirements).
Are there other legal exemptions?
Yes. You don’t have to get the shots if you’ve already
had one of the diseases such as measles, mumps, or
rubella. Or your doctor can
sign an exemption if you have another medical reason
not to be vaccinated (like you’ve had a lab test
showing you’re immune or you’re pregnant).
You may also have religious or philosophical
objections to being immunized. If so, you can submit
a notarized statement of your beliefs.
What if I can’t find my shot record?
Try to remember where you were immunized, and see
if your doctor or clinic still has the records. Your
parents may be able to help. If you attended school in
Minnesota (before college) your former school district
may still have your records.
If you still can’t find your records, you’ll probably
have to repeat the shots. This time, be sure to keep a
Are the shots safe?
The vaccines are very safe and highly effective. There
can be side effects, but they are usually brief and not
very serious a slight fever, a sore arm, a mild feeling
of illness. More severe side effects do occur, in rare
cases. But that risk
Immunization Program
P.O. Box 64975
St. Paul, MN 55164-0975
651-201-5503 or 1-800-657-3970
mumps may experience swelling of the testicles. In
rare cases, sterility can result.
Rubella is usually a mild disease in children. But
it can be very serious if a grown woman gets
rubella during the first three months of pregnancy.
The disease can cause serious birth defects
including glaucoma, cataracts, deafness, and
mental retardation.
Tetanus or “lockjaw” can lead to fatal
complications. Even small burns or scratches can
be a source of infection, and deep puncture wounds
are especially dangerous.
Diphtheria is a serious bacterial disease that
affects the tonsils, throat, nose, and/or skin. It can
lead to breathing problems, heart failure, paralysis,
and sometimes death.
Hepatitis B is a liver disease caused by the
hepatitis B virus (HBV). Hepatitis B is a highly
contagious disease that infects the liver and can
lead to cirrhosis, liver cancer, and even death.
Hepatitis B is spread through contact with the
blood of an infected person or by having sex with
an infected person.
Hepatitis A is a liver disease caused by the
hepatitis A virus (HAV). Hepatitis A can affect
anyone. Hepatitis A is still a common disease in
the United States and is spread by close contact
with someone who is infected. It is also spread by
contaminated food and water. Adults need hepatitis
A vaccine for long-term protection.
Hepatitis C is a liver disease caused by the
hepatitis C virus (HCV), which is found in the
blood of persons who have this disease. The
infection is spread by contact with the blood of an
infected person. Most persons who get hepatitis C
carry the virus for the rest of their lives. There is
no vaccine to prevent hepatitis C.
Meningococcal disease is a serious illness, caused
by a bacteria. Meningococcal disease is a leading
cause of meningitis, an infection of the lining of
the brain and the spinal cord. Meningococcal
disease also causes blood
Page 1 of 2
has to be compared with the risk you will
face if you don’t get immunized. Without
shots, your chances of becoming ill and
suffering serious complications are much
Where can I get the shots?
Your own physician can provide the shots
you need. If you don’t have a physician, or
you don’t have health insurance, you may
be able to get the shots through a
community clinic. Call your county or city
health department for more information.
Your college may also offer the shots
through the health service or a special
immunization clinic.
If I’m not required to receive
hepatitis A and B and
meningococcal shots, should I
still get them?
Yes. For example:
• College freshmen living in dorms or
close living quarters are at a higher
risk for meningitis. There is a vaccine
to protect against the disease.
• Hepatitis B is a highly contagious
disease that infects the liver. The
highest rate of disease occurs in
persons 20-49 years of age.
• Hepatitis A is still a common disease
in the United States. Hepatitis A
symptoms are much more severe in
adults than in children. Infected
persons may need to rest in bed for
days or weeks, and won’t be able to
drink alcohol until they are well.
• If you will be traveling
internationally, it’s likely you’ll need
even more shots. Be sure to check
with your doctor to see what
additional shots you might need.
(MDH 4/06)
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Minnesota’s College Immunization Law – page 2
Minnesota Department of Health
Minnesota’s College Immunization Law