Varicella Immunization Cert

Varicella (Chicken Pox)
Certificate of Immunization
MIDDLE TENNESSEE STATE UNIVERSITY REQUIRES FULL-TIME STUDENTS TO PROVIDE PROOF OF TWO (2) DOSES OF
VARICELLA (CHICKEN POX) VACCINE OR PROOF OF IMMUNITY OR DOCUMENTATION OF DISEASE HISTORY FROM
A HEALTH CARE PROVIDER. YOU WILL NOT BE ALLOWED TO REGISTER FOR MORE THAN 11.99 HOURS FOR UNDER-
GRADUATES OR MORE THAN 8.99 HOURS FOR GRADUATES UNTIL AN ACCEPTABLE FORM IS ON FILE IN THE STUDENT
HEALTH SERVICES OFFICES.
Please disregard this form if you were born before 1980.
PART I
(to be completed by student)
Name_______________________________________________________________________________________________________
Last First Middle
Date of birth_____________________________________________ Student ID No. M_____________________________________
PART II
(to be completed and signed by physician)
(Dates must include month and year)
month day year
Varicella-Check appropriate box:
 Immunized with Varicella vaccine 1. __________ ____________ ___________
2. __________ ____________ ___________
 Has Varicella titer confirming

disease immunity __________ ____________ ___________
 Medically contraindicated because of medical condition

(i.e. allergy to vaccine, pregnancy, etc.)
Must list reason(s):_________________________________________________________
 History of disease__________________________________________________________

________________________________________________________________________

________________________________________________________________________
Signature of Provider_______________________________________________________
Health Care Provider

(Please print unless office stamp is used)
Name ______________________________________________________________________________________________________
Address _____________________________________________________________________________________________________
Signature ______________________________________________________________ Office phone ________________________
To submit: The student will go to the following link: https://shsweb.mtsu.edu/. The student will log into their student portal and
follow the directions to upload immunizations directly into their student record.
1113-0634 – MTSU is an AA/EEO employer.
Student Health Services
MTSU Box 237
Murfreesboro, TN 37132
Phone: (615) 898-2988
Fax: (615) 898-5004
Notification of Varicella (Chicken Pox) Immunization Policy

Who is required to be immunized?
New full-time enrollees in higher education institutions (post-secondary) in Tennessee with enrollments larger
than 200 students.
• New undergraduates enrolled in at least 12 semester hours, or equivalent
• New graduate students enrolled in at least 9 semester hours, or equivalent
Who is exempt?
• Date of birth before 1980
• Full-time distance learning students are exempted from immunization requirements
• Medical exemption: Physician or health department indicates that certain vaccines are medically
exempted (because of risk of harm). Any vaccines not exempted remain required.
• Religious exemptions: Requires a signed statement by the student that vaccination conflicts with his
or her religious tenets of practices.
How do I show proof of immunity? (Use form on back of page)

Proof of immunity to varicella (chicken pox) is required by meeting one of the following three criteria:
1. History of chicken pox illness diagnosed by a health care provider or verified by a physician, advanced
practice nurse or physician assistant to whom the illness is described, or
2. Documentation of two doses of varicella vaccine given at least 28 days apart, excluding doses given ear-
lier than 4 days before the first birthday, or
3. Documentation of blood test (serology) showing immunity to varicella.
YOU WILL NOT BE ABLE TO REGISTER FOR FULL-TIME HOURS UNTIL AN ACCEPTABLE FORM IS
ON FILE IN THE STUDENT HEALTH SERVICES OFFICE. Submit form at https://shsweb.mtsu.edu/. Log
into the student portal and follow the directions to upload immunizations.
Where can I get the vaccine?

• The vaccine is available at MTSU Health Services for $115 per dose (price subject to change). Call
615-898-2988 to schedule an appointment.
• Check with your local health care provider or health department for availability.
Where can I get the blood test to check for immunity?

• Students may get a Varicella titer blood test at the MTSU Health Services.
• Students may visit their local health care provider for this test.
• Blood tests to check for evidence of immunity are not available through health departments.
I am having trouble finding my records. Any suggestions?

Adults can have difficulty locating childhood immunization records. Check with family member, original
immunization provider, local health department, or previous schools attended. If records cannot be located,
vaccination is recommended. Additional doses of vaccine are not harmful. For more information, visit http://
twis.tn.gov or http://health.state.tn.us/CEDS/required.htm.
We hope you found the information above to be helpful. If you have further questions, please call Health
Services at 615-898-2988.

Varicella Immunization Cert

Uploaded by

Copyright:

Available Formats

Varicella Immunization Cert

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Varicella Immunization Cert

Uploaded by

Copyright:

Available Formats

Varicella (Chicken Pox)

Please disregard this form if you were born before 1980.

Date of birth_________ Student ID No. M_

 Immunized with Varicella vaccine 1. _

2. _

 Has Varicella titer confirming

 Medically contraindicated because of medical condition

Health Care Provider

Signature ______________________________________ Office phone

Notification of Varicella (Chicken Pox) Immunization Policy

How do I show proof of immunity? (Use form on back of page)

Where can I get the vaccine?

Where can I get the blood test to check for immunity?

I am having trouble finding my records. Any suggestions?

You might also like