PHYSICIAN COMPLETES
STUDENT
COMPLETES
Proof of Immunization Compliance
(Louisiana R.S. 17:170 Schools of Higher Learning)
(Louisiana ACT 251 and 711)
Name: _________________________________________________________________________________
Please Print
(Last) (First) (MI)
BANNER / Student ID # ________________________________
Date of Birth: _________________________________________
Month Date Year
PHYSICIAN OR OTHER HEALTH CARE PROVIDER VERIFICATION: (See other side)
Measles (Rubeola) Rubella Mumps TDaP Meningitis
1st Immunization: _______ Immunization: _______ Immunization: _______ Immunization: _______ 1st Immunization:______
(Date) (Date) (Date) (Date) (Date within 10 yrs.)
and or or or
2nd Immunization:_____
(Date win 10 years)
2nd Immunization: _______ Serologic Test: _______ Date of Disease: _______ Serologic Test: _______
(Date) (Date) (Date) (Date)
or and or or
Date of Disease: _______ Result: _______ Serologic Test: _______ Result: _______
(Date) (Date) (Date and Result) (Date)
or
Serologic Test: _______
(Date and Results)
__________________________________________ ________________
(Signature of Physician or Other Health Care Provider) (Date)
(Please Place Address or Stamp Above)
WAIVER OF VACCINATION AND RELEASE FROM RESPONSIBILITY:
I UNDERSTAND THAT MY HEALTH COULD BE NEGATIVELY AFFECTED AND MY LIFE POSSIBLY ENDANGERED BY NOT RECEIVING THE ABOVE
LISTED VACCINES.
The reason for not being vaccinated is:
Personal
Unavailability of the vaccine (I have provided a statement verifying that I have tried to receive the vaccine but no vaccine could be found)
I am an online student and will not be on campus for classes
Medical
Religious
I declare myself to be a person of the full age of majority and to be mentally competent. I hereby assume full responsibility for any and all possible present
or future results or complications of my condition due to this refusal. If I am not of full age of majority, my parent or legal guardian must sign below.
I do further hereby now and forever free and release Bossier Parish Community College and the Department of Health and Hospitals and all its agents,
attending health care professionals, and other personnel from any and all legal or financial responsibility as a result of this refusal.
I certify that I have read (or had read to me) and that I fully understand this release from Responsibility. All explanations were made to me and all blanks
lled in before I signed my name.
___________________________ _____________
Month Day Year Time
_______________________________________________
Student’s Signature
____________________________________________
Parent or Guardian, if required
Form No. DC 1411.1 (8/06)
Revised June 2018
IMPORTANT:
Make a copy of this form for your personal record.
Return via fax to (318) 678-6390 or
email to admissions@bpcc.edu
Bossier Parish Community College
accepts state
-i
ssued immunization records
OR this form signed by your physician.
click to sign
signature
click to edit
click to sign
signature
click to edit
Louisiana law requires immunization against measles, mumps, rubella, whooping cough (Pertussis), Meningococcal Disease, and
tetanus-diphtheria for all first-time Bossier Parish Community College students born after 1956.
TO THE NEW STUDENT:
Where to locate your immunization record(s): Your immunization (shot) record may be found in your family records, such as a baby
book, or in a booklet that may have been written in by your doctor or public clinic each time you received a vaccination. You may
also want to check for records with your doctor or public health clinic. Please keep in mind, however, that immunization records are
maintained for a variable number of years, and than usually only be the medical provider who actually gave the vaccines to you.
As a last resort, and if you are a graduating high school senior, school personnel may be able to locate immunization records in
your cumulative or health folder before your graduation. After you graduate, records are sent to storage and may not be accessible.
Shot records or reasonably authentic copies of records (such as those from a baby book or school health record), which indicate
specic information such as your name, date of birth, and the dates of the shots you had, should be acceptable documentation of
the immunizations you received previously. These records should be taken with you to your doctor or a local public health clinic
for a possible up-date of your immunization status. A visit to your doctor or public health clinic will be needed to have your Proof of
Compliance form signed and/or to interpret your old records in view of changes in health care standards since your early childhood.
Take care of this important matter as soon as you can, and most certainly before registration.
TO THE PHYSICIAN OR OTHER MEDICAL PROVIDER:
(Please do not sign this compliance form unless the student has proper vaccines or immune tests.)
The following guidance is presented for the purpose of implementing the requirements of Louisiana R.S. 17:170, and of meeting the
established recommendations for control of vaccine-preventable diseases as recommended by the American Academy of Pediatrics
(AAP); the advisory Committee on Immunization Practices to the United States Public Health Service (ACIP); and the American College
Health Association (ACHA).
Requirements: Two (2) doses of measles vaccine; at least one (1) dose each of rubella and mumps vaccine; and a TDaP booster;
meningococcal vaccine.
Measles Requirement: Two (2) doses of live vaccine given at any age, except that the vaccine
must
have been given on or after the
rst birthday in 1968 or later, and without Immune Globulin. A second dose of measles vaccine must meet this same requirement, but
should not have been given within 30 days of the rst dose. A history of physician-diagnosed measles is acceptable for establishing
immunity, but should be accepted with caution unless you were the diagnosing physician.
Tetanus-Diphtheria Requirement: A booster dose of vaccine given within the past ten (10) years. Students can be considered to have
completed a primary series earlier in life, unless they state otherwise.
ALL FIRST TIME FRESHMAN REGARDLESS OF AGE MUST PROVIDE:
Meningococcal Vaccine Requirement: One dose of vaccine given within the past ten (10) years.
NOTE: In most cases, student compliance will require a second dose of measles vaccine (preferably as MMR) and a dose of tetanus-
diphtheria (Td, Adult Type). In cases where no records can be located, or especially when immunization in the past is doubtful, two
doses of MMR separated by a minimum of 30 days may be indicated. Evidence of vaccination or immunity against measles, rubella,
mumps, tetanus and diphtheria can be established by either reviewing a previous written record of vaccination
or administering vaccine now. Serologic testing is acceptable evidence of immunity, but should not be routinely performed unless
specifically requested by the patient, and if testing is appropriate or available. Practically speaking, immunization is preferable to
serologic testing because of the relative costs and time. In all instances when vaccine administration is considered, M-M-R (measles,
mumps and rubella vaccine live) and tetanus-diphtheria toxoid (Td, Adult Type) are the products of choice for use in adults unless a
specific contraindication is present.
Bossier Parish Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees, diplomas, and certificates. Contact the
Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of Bossier Parish Community College. Bossier Parish
Community College does not discriminate on the basis of race, color, national origin, gender, age, religion, qualified disability, marital status, veteran's status, or sexual orientation in admission to its
programs, services, or activities, in access to them, in treatment of individuals, or in any aspect of its operations. Bossier Parish Community College does not discriminate in its hiring or employment
practices. Coordinator for Section 504 and ADA: Angie Cao, Student and Disability Services Specialist - Disability Services, F254, 6220 East Texas Street, Bossier City, LA 71111 - (318) 678-6511 -
acao@bpcc.edu. - 8:00 a.m.–4:30 p.m. M-F, excluding holidays and weekends. Equity/Compliance Coordinator: Teri Bashara, Director of Human Resources - Human Resources Office, 6220 East
Texas Street, Bossier City, LA 71111 - (318) 678-6056 - 8:00 a.m.–4:30 p.m. M-F, excluding holidays and weekends.
Revised June 2018