Page 1 of 1. Rev. 2/2018. Office of the Registrar. 8245 SW Barnes Road. 8245 SW Barnes Road ⢠Portland, OR 97225. T 97
Office of the Registrar 8245 SW Barnes Road 8245 SW Barnes Road • Portland, OR 97225 T 971-255-4230 • F 503.297.9651
[email protected] • ocac.edu
Immunization Form In accordance with the Oregon State Health division, students attending college in Oregon are required to show evidence of immunity to measles (rubeola.) Dates of immunization accompanied by the student signature are accepted as evidence. This form is required for all entering undergraduate and graduate students at OCAC. Students who do not submit the form will be blocked from registering for classes. Name __________________________________________________________________________________________________________________ Last
First
Middle
Date of birth ______/______/____________
VACCINE HISTORY (check one only): I have had two doses of measles vaccine at least 28 days apart. The first dose was at or after the age of 12 months. First Dose Date _____________________ Second Dose Date _____________________ I have had two doses of measles vaccine, but do not know the date of the first immunization. I was born before January 1, 1984 and I had my second measles immunization on or after December 1989. Second Dose Date __________________ I am exempt from the measles vaccination requirement because (check one): I was born before January 1, 1957. I am immune to measles. A measles titer (blood test) report is attached. I had the measles. A signed physician statement is attached indicating the date of the infection. I have a medical reason for not receiving the immunization. A signed physician statement is attached. My non-medical beliefs prohibit my use of the immunization. I have watched the State of Oregon College Vaccine Education Module, and my Vaccine Education Certificate of Completion is attached.
SIGNATURE REQUIREMENT I certify that the above information is true and complete by the best of my knowledge
Signature
Rev. 2/2018
Date
