Wisconsin State Law (Assembly Bill 344) requires students to sign an acknowledgement statement related to Meningitis and Hepatitis B. By signing and submitting this Immunization Record, you acknowledge that you have read the Vaccine Information Statements for Meningococcal disease and Hepatitis B.
2. If you do not have a scanned or electronic record of your immunizations available, please enter the dates of the vaccinations you have received below, then sign and submit the form.
DIPHTHERIA TETANUS PERTUSSIS (DTP)
You must have had a Tetanus shot within the past 10 years.
VARICELLA (CHICKEN POX) OR DATE OF DISEASE
TB SKIN TEST
My signature below indicates that all the information on this form is true to the best of my knowledge. My signature also verifies that I have read the Vaccine Information Statements for Meningococcal disease and Hepatitis B online.