Immunization Information Form
Please enter the appropriate dates for your immunization information.

If you have a Medical Exemption or Conscientious Exemption please download this form and mail it back to the Admission Office. Exemption Form:
http://info.csp.edu/globalassets/student-services/health-services/docs/Exemptions.pdf

Student ID *
You received your Student Id in your application letter.
Your answer
First Name *
Your answer
Last Name *
Your answer
Middle Initial
Your answer
Required Immunization Dates
Most recent DT (Diphtheria-Tetanus) within the past 10 years *
(mm/dd/yyyy)
Your answer
MMR - 1 (Measles, Mumps, Rubella) *
First dose of immunization (mm/dd/yyyy)
Your answer
MMR - 2 (Measles, Mumps, Rubella) *
Second dose of immunization (mm/dd/yyyy)
Your answer
Recommended Immunization Dates
Hepatitis B - 1
First dose of immunization (mm/dd/yyyy)
Your answer
Hepatitis B - 2
Second dose of immunization (mm/dd/yyyy)
Your answer
Hepatitis B - 3
Third dose of immunization (mm/dd/yyyy)
Your answer
Menactra
(mm/dd/yyyy)
Your answer
Varicella - 1
First dose of immunization (mm/dd/yyyy)
Your answer
Varicella - 2
Second dose of immunization (mm/dd/yyyy)
Your answer
HPV - 1 (Human Papillomavirus)
First dose of immunization (mm/dd/yyyy)
Your answer
HPV - 2 (Human Papillomavirus)
Second dose of immunization (mm/dd/yyyy)
Your answer
HPV - 3 (Human Papillomavirus)
Third dose of immunization (mm/dd/yyyy)
Your answer
Hepatitis A - 1
First dose of immunization (mm/dd/yyyy)
Your answer
Hepatitis A - 2
Second dose of immunization (mm/dd/yyyy)
Your answer
Doctor of Physical Therapy Students ONLY
Influenza (flu)
(mm/dd/yyyy)
Your answer
Polio
(mm/dd/yyyy)
Your answer
Pneumococcal (pneumonia)
(mm/dd/yyyy)
Your answer
Tetanus-diphtheria-acellular pertussis (primary series)
(mm/dd/yyyy)
Your answer
Tuberculosis TB
(mm/dd/yyyy)
Your answer
Form Submission
By submitting this form, I certify that the above dates are accurate information and that I have received the immunizations required by Minnesota State Law (M.S. 135A. 14).
Submit
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