Minnesota Law (M.S. 135A.14) requires that all students born after December 31, 1956, and enrolled in a private or public
post-secondary school or living in on-campus housing, be immunized against diphtheria, tetanus (Td), measles, mumps and
rubella (MMR), with the exception of students who graduated from a Minnesota high school in 1997 or later (because they
will have already met the immunization requirements as a high school student). This form is designed to provide the school
with the information required by law and will be available for review by the Minnesota Department of Health and the local
community health board.
Enter the month, day (if available) and year of the most recent "booster" for diphtheria and tetanus (must be within the
past 10 years) and all doses of vaccine for measles, mumps and rubella that were given after 12 months of age.