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University Health Center

College of Nursing

Hep B Meningitis Waiver

Hepatitis B/Meningitis Immunization History Form (PDF)

This form is for legal purposes only.  Completion of this form does not constitute submission or refusal of receiving required vaccinations. 

This form does not exempt you from the Meningococcal vaccine if you plan to live on campus.  You will be required to submit your Meningococcal vaccine separately if under 22 and living on campus. 

If you are under 18, a parent or guardian must complete and submit this form for you.  You cannot register without this form on file. 

Over 18, you will complete this form online at the time of registration for classes at your Orientation. Do not submit a paper form.


Privacy Information Protected

HIPAA Notice of Privacy Policy Practices (pdf)

This Notice describes how medical information about you may be used or disclosed and how you can get access to this information. Please review it carefully.


Privacy Information Protected

Immunization Form (pdf)

It is highly recommended the Immunization Form be received 30 days prior to your on campus orientation or registration. Failure to do so may impact your ability to register for classes.


Immunization Form.

Immunization Waiver (online) 

For Online Classes ONLY. Submit and follow up with the Registrar's Office.


Form

Immunization Waiver (doc) 

For Online Classes ONLY. Submit and follow up with the Registrar's Office.


Online form

Immunization One-time Waiver (online)

Only first time students at ETSU who are missing either the Varicella 2 or MMR 2 are eligible. Submit and follow up with the Registrar's Office.


Forms

Immunization One-time Waiver (pdf)

Only NEW first time students who are missing either the Varicella 2 or MMR 2 are eligible. If you received this exemption at another Tennessee school and are transferring in, you would not be eligible for this 30 day waiver. If you qualify for this exemption, submit this form to the Registrar's Office and then submit your proof of receiving your second vaccine in 30 days to Student Health Services.


Medical Waiver

Medical Waiver (docx) fax form and signed medical statement to: 423-439-4560


Release

Release of Medical Information (From Outside Provider to ETSU University Health Center) (pdf)

Release of Medical Information (From ETSU University Health Center to Outside Provider) (pdf)

This must be completed before we can fax or mail any information to the patient or third party, at the request of the patient.

Costs apply depending on the number of pages you are requesting, please call for an exact price 423-439-4225. Prepayment is required!  Please allow 2 weeks for processing, and any information will only be sent to ONE address.


Religious Exemption

Religious Exemption (docx)

Requires Notary Authorization.


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