The document is a measles vaccine requirement form from Portland State University's Center for Student Health & Counseling, which requires all incoming students born after 1956 to provide documentation of two MMR vaccine doses or qualify for a medical or non-medical exemption. It details the vaccine dose dates required, exemption criteria and submission instructions, noting any documentation will be shredded and exemptions may require the student to be excluded during disease outbreaks.
The document is a measles vaccine requirement form from Portland State University's Center for Student Health & Counseling, which requires all incoming students born after 1956 to provide documentation of two MMR vaccine doses or qualify for a medical or non-medical exemption. It details the vaccine dose dates required, exemption criteria and submission instructions, noting any documentation will be shredded and exemptions may require the student to be excluded during disease outbreaks.
The document is a measles vaccine requirement form from Portland State University's Center for Student Health & Counseling, which requires all incoming students born after 1956 to provide documentation of two MMR vaccine doses or qualify for a medical or non-medical exemption. It details the vaccine dose dates required, exemption criteria and submission instructions, noting any documentation will be shredded and exemptions may require the student to be excluded during disease outbreaks.
The document is a measles vaccine requirement form from Portland State University's Center for Student Health & Counseling, which requires all incoming students born after 1956 to provide documentation of two MMR vaccine doses or qualify for a medical or non-medical exemption. It details the vaccine dose dates required, exemption criteria and submission instructions, noting any documentation will be shredded and exemptions may require the student to be excluded during disease outbreaks.
Phone: 503.725.2800 Fax: 503.725.5812 1880 SW 6th Ave. Portland UCB Suite 200 PO Box 751 Portland, OR 97207
Measles Vaccine Requirement Form (MMR)
Contact Information
Rory Elliott 12 17 1997
Student Name: ____________________________________________ Date of birth: ________/__________/__________ Month Day Year 938505873 re7@pdx.edu PSU ID#: _________________________________ Email:___________________________________________________
Measles Requirement
The Oregon State System of Higher Education requires all incoming students to show evidence of immunity to measles (Rubeola). The immunity to measles (Rubeola) is usually administered via the Measles, Mumps, and Rubella (MMR) vaccine.
All entering students born after December 31, 1956 must have the following: ● Two vaccinations of MMR. The first vaccination must be received at least 1 year after date of birth. There must be a minimum of 28 days between the first and second vaccinations. Please indicate the dates on which the two required doses of MMR vaccination were received*
04 23 1999 Dose #1: _________/__________/____________ Month Day Year 09 09 2002 Dose #2: _________/__________/____________ Month Day Year
12 18 2020 Student Signature (required): ___________________________________ Date: ________/__________/____________ Student Signature Month Day Year
* No medical records or documentation are necessary, simply submit the dates when your vaccinations were received. If you submit documentation, it will be shredded.
● If you do not meet the requirements outlined above, please see the reverse side regarding exemptions.
Submission Details You may submit the completed form in either of the following way listed below. Do not send original medical/immunization documents. This document will be shredded after input.
Mail: Fax: Center for Student Health & Counseling Fax: 503.725.5812 Mail Code: SHAC Fax white paper ONLY P.O. Box 751, Portland, OR 97207
Email: Submit a scanned copy to: measles@pdx.edu Questions? Submit your questions to measles@pdx.edu
v12.14.2020 Age Exemption Initial here if you were born before 1957: _______________
Medical & Non-Medical Exemptions
Individuals with medical or non-medical exemptions(s) (except a verified history of disease or blood test indicating immunity to measles (Rubeola)) are not protected against measles (Rubeola). This means that they are at risk for getting the disease. In the event of an outbreak, individuals with an exemption for measles (Rubeola) may be excluded from the University, under the direction of the student Health Services Director and/or the local Health Officer.
܆Medical Exemption Acceptable bases include: o Serious allergic reactions (anaphylactic) to Gelatin, Neomycin, or other vaccines. o Pregnancy or intent on becoming pregnant within 28 days. o Immuno-suppression such as occurs with cancers (leukemia, lymphoma) or medications for such diseases. o Taking high doses of cortisone-type medications for more than 2 weeks. Note: All medical exemptions require a physician’s signature. Individuals with HIV-positive antibodies or with leukemia in remission who have not received chemotherapy for at least three months may receive MMR vaccine. Physician’s Certifications I certify that this individual should be exempted from the MMR vaccine requirements based on: A. History of Measles (Rubeola): Date: __________/___________/____________ B. Measles (Rubeola) Immune Titer: Date: __________/___________/____________ C. The following medical reason: _____________________________________________ Which constitutes a medical contraindication in accordance with the advisory committee on immunization practices of the U.S. Public Health Services for MMR vaccine (see above). Physician’s Signature: ___________________________________ Date: _______/________/________ Physician’s Address: ____________________________________ Phone: _____-________-_________ ܆Non-Medical Exemption Under the Oregon State Immunization Law, as of March 1, 2014 those claiming a non-medical exemption are required to complete one of the following: A. Video Tutorial (An online video tutorial at www.healthoregon.org/vaccineexemption) I am adherent to a religion, the teachings of which are opposite to immunization; or I prescribe to a spiritual or philosophical belief that opposed immunization, and therefore request that I be exempt from the immunization requirement. I have watched the required video advising me about the risk factors involved in not being immunized against certain infectious diseases and the required Certificate of Completion attached. Student’s Signature: ___________________________________ Date: _______/________/________ B. Consultation with a health care provider (medical doctor [MD], osteopath [DO], registered nurse working under the direction of an MD or DO; naturopathic doctor, nurse practitioner licenses to prescribe medication, or physician’s assistant). Provider Counseling (to be completed by an approved health provider (see above). I, ____________________________ (provider printed name), have counseled this student on the risk factors involved in not being immunized against certain infectious diseases.
