Minnesota Statutes Section 121A.15 requires children enrolled in a Minnesota school to be immunized against certain diseases, allowing for certain specified exceptions.  This form is designed to provide the school with information  required by the law and will be available for review by the Minnesota Department of Health and the local community health board.

Enter the MONTH, DAY, and YEAR for all vaccines the pupil received. DO NOT USE (✔) or (✘).

*       Hepatitis B is required for kindergarten and 7^th grade.

**     Varicella vaccine will be required starting fall 2004.

***    PCV and Hib vaccines are recommended only for children through age 4 years.

Note for school personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it.  Also, record combination vaccines (e.g., DTaP+Hib, Hib+HBV) in each applicable space.

Indicate immunization status and source of above information by choosing one of the following:

�      I certify that this student has received all immunizations required by law.

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      Signature of parent/guardian or physician/public clinic                                                    Date

�      I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B (K + 7^th), varicella (K + 7^th), measles, mumps, and rubella and will complete his/her diphtheria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months. The dates for which the remaining doses are to be given are:

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Signature of parent/guardian or physician/public clinic                                                    Date

Legal Exemptions to Minnesota School Immunization Law

CStudents 7 years of age or older do not need pertussis vaccine.

CStudents 18 years of age or older do not need polio vaccine.

CMedical exemption: No student is required to receive an immunization if they have a medical contraindication or laboratory evidence of immunity.  To receive a medical exemption, a physician must sign the following statement:

I hereby certify that immunization is contraindicated for medical reasons or that laboratory confirmation of adequate immunity exists for the following immunizations

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Signature of physician                                                                                                    Date

CConscientious exemption: No student is required to have an immunization which is contrary to the conscientiously held beliefs of his/her parent or guardian.  To receive this exemption, a parent or legal guardian must complete and sign the following statement and have it notarized:

I hereby certify by notarization that immunization for my child is contrary to my conscientiously held beliefs. Indicate vaccine(s):

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Signature of parent or legal guardian                                                                            Date

Subscribed and sworn to before me this _______ day of______________________20______

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Signature of notary

Special Exceptions for DTP, Td, Polio, and Hep B

CChildren less than 7 years of age: The 5^th dose of DTaP/DTP/DT (similarly, the 4^th dose of polio vaccine) is not necessary if the 4^th DTaP/DTP/DT (3^rd dose of polio) was administered after the 4^th birthday.

CChildren 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td and 3 doses of polio vaccine meets the minimum requirements of the law.

CStudents in grades 7-12: A Td booster at age 11 years or later is not required for students in grades 7-12 whose most recent Td was given after their 7^th birthday but before their 11^th birthday. Instead, it will be required 10 years after the date of the most recent dose. Enforcement of theTd booster requirement will be reinstated in the fall of 2004 for all 7^th-12^th graders.

CStudents 11-15 years of age: A 3^rd dose of hepatitis B vaccine is not required for those students who provide documentation of the alternative 2-dose schedule.