immunizations up to date. An immunization record document has been signed by the student's medical provider and uploaded into the NLU PA Program student file.
☐ The NLU PA student, ________________________________________, Student ID Number ________________________, has a medical contraindication or other approved exception to one or more required immunizations, as documented through the appropriate NLU and PA Program process.
Unless Contraindicated or Exception Applies — Explanation
Applicable Immunization(s):
Reason for Contraindication or Approved Exception:
Documentation of contraindication or exception has been maintained through the appropriate confidential process:
☐ Yes ☐ No ☐ Not Applicable
Date Compliance Status Verified: ____________________________
Student Verification and Acknowledgment
I acknowledge that I have reviewed the NLU PA Program immunization requirements and have provided the required documentation or completed the appropriate process for any applicable contraindication or approved exception.
Student Name: ___________________________________________
Student Signature: ________________________________________
Date Signed: _____________________________________________
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