MIDDLE TENNESSEE STATE UNIVERSITY REQUIRES FULL-TIME STUDENTS TO PROVIDE PROOF OF TWO (2) DOSES OF 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Part I, enter your full name, date of birth, and student ID number. Ensure all information is accurate for proper identification.
3. Proceed to Part II, which must be completed by a physician. This section includes vaccination details for Varicella and MMR. Check the appropriate boxes based on your immunization status.
4. If you have had the diseases confirmed by medical records, select the corresponding options and provide dates as required.
5. For any medical contraindications, clearly list the reasons in the designated area provided by your healthcare provider.
6. Ensure that your healthcare provider fills in their name, address, and signature before submitting the form.
7. Once completed, save your document and submit it via email or fax to MTSU Health Services as instructed.

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