For on campus residents only:

All forms are available at www.missouriwestern.edu/healthserv/

_____ Read Immunization Policy & Instructions

_____ Complete and sign Health History Form

_____ Complete Tuberculosis Risk Assessment Form, get testing if indicated and

          have provider sign form

_____ Complete Immunization Documentation Form, to be done and signed by

          healthcare provider, or provide Health Department, Physician, or School record

_____ Complete waiver, if appropriate.

_____ Return all forms (Health History Form, Tuberculosis Risk Assessment,

           Immunization Documentation Form, and waiver (if applicable) to:

                             Esry Student Health Center

                             Missouri Western State University

                             4525 Downs Drive - Blum 203

                             St. Joseph, MO  64507-9987