CERTIFICATE OF IMMUNIZATION

In compliance with Tennessee state law, all Board of Regents institutions are requiring proof of two immunizations with the Measles, Mumps, and Rubella (MMR) vaccines.  These shots need to have been administered after your first birthday in order to attend classes. 
    
You must have this form completed and signed by a licensed health care provider.  You must download or print this form.

EXEMPTIONS

If you graduated from a Tennessee high school after 1998

If you were born before Jan. 1, 1957

 
Please send the completed document to the following address:

Austin Peay State University
Student Health Services
P.O. Box 4655
Clarksville, TN  37044
Or fax it to (931) 221-7388
        
Name(:print)                                                                                                
___________                                                                                            
Address:                                                                                                 
City:                                                      State:         ZIP:                  
Phone:                                                                    

Date of Birth: ___________________

Please complete one of the following sections

        1.
 Date of MMR #1 _____ / _____ / _____
Date of MMR #2 _____/_____/_____
  
        2. OR, Clinical diagnoses of:
Measles:  Year: ____ 
Mumps:  Year: ___ 
Rubella:  Year: _____
   
        3. OR, Laboratory proof of immunity:
Measles:  Year: _____ Titer: _____
Mumps:  Year: _____  Titer: _____  
Rubella:  Year: _____  Titer: _____
      
_____4. OR, Medically contraindicated (allergy, pregnancy, other).  Please attach provider's statement regarding medical condition.
     
_____5. OR, Refuse immunizations due to religious objections.  Please attach letter of explanation from licensed member of clergy and/or be notorized.
   
    
Health Care Provider:		     
Name:                                                                     
Signature:                                                               
Address:  _                                                              
                                                                             
Phone:  (         )          -               

We urge you to give this your immediate attention.  If you have any questions, please call (931) 221-7107. Austin Peay State University, a Tennessee Board of Regents Institution, is an equal opportunity employer committed to the education of a nonracially identifiable student body. ap450/02-08/5m

Revised: January 2008   

 

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