Certificate of Immunization for Student Health Services

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Oregon state law mandates that 4 year college students* provide evidence of measles (rubeola) vaccine or file for exemption.  The first dose of measles must be within 4 days prior to, on, or after the first date of birth. There must be a minimum of 24 days between the 2 doses. Usually listed as MMR.
*You must submit this form if you were born after January 1, 1957 and taking 12 or more credits (undergrads) and 6 or more credits (grads). If you are taking classes solely online, you do not need to submit this form.

Yes I had 2 doses of measles (rubeola) vaccine after age 12 months. Doses were at least 28 days apart. Please submit dates of immunization below.

Born prior to 1984? If date of #1 is not available then date of #2 must be after December 1, 1989

Please Indicate Immunization Exemption
You will be required to provide documentation of exemption to Concordia University's Health Services Director. Forms can be mailed to 2811 NE Holman St., Portland, OR 97211 or dropped off at the 3 to PhD Wellness Center on the first floor of Faubion. Do not submit original medical/immunization documents.
*Click here for documentation options for non-medical exemptions

Entering your name into the signature block above indicates that you certify that all information submitted is true and correct.

For questions about this form, please contact the Concordia Health Services Director at studenthealthservices@cu-portland.edu