Cds Form - Niagara College (Page 2 of 2) in pdf

Name:

__________________________________________________

Page 2 of 2

Section 2 – REQUIRED continued

COPIES OF YOUR VACCINATION RECORDS and LAB REPORTS MUST BE ATTACHED

2. MEASLES, MUMPS, RUBELLA (MMR) IMMUNITY:

Proof of Measles, Mumps, Rubella immunity is required. Only the following will be accepted:

A documented history (vaccination record) of two doses of MMR.

or - Laboratory evidence (lab report) showing immunity to Measles, Mumps, and Rubella.

Proof of 2 MMR vaccination dates: (vaccination record must be attached to this form)

Date of 1

MMR: _________________________

Date of 2

MMR: _________________________

OR …

Proof of immunity (lab report must be attached to this form)

Blood work dates: Measles Immunity: _______________________

Mumps Immunity: _______________________

Rubella Immunity: _______________________

3. VARICELLA IMMUNITY

Proof of Varicella (chicken pox) immunity is required. Only the following will be accepted:

Laboratory evidence (lab report) showing immunity to Varicella

or - A documented history of two doses of Varicella vaccine (vaccination record)

Proof of immunity (lab report must be attached to this form)

Blood work date: Varicella Immunity: _______________________

OR …

Proof of 2 Varicella vaccination dates: (vaccination record must be attached to this form)

Date of 1

dose: _________________________

Date of 2

dose: _________________________

Section 3 - STRONGLY RECOMMMENDED

4. TETANUS DIPHTHERIA:

Last immunization Date: ___________________________________

Last immunization date

within 10 years)

(

5. PERTUSSIS:

Last immunization Date: _________________________

6. HEPATITIS B

Vaccine: Date 1

dose: _____________ Date 2

dose: ____________ Date 3

dose: _____________

INFLUENZA:

Immunization Date:___________________ Date must be provided prior to placement start

NOTE: This information may be submitted later in the term if current influenza vaccine is not available.

Section 4 - Health Professional’s Signature: (Must be completed)

Stamp

Name: _________________________________________

Address: _______________________________________

Phone: _______________________________________

Health Professional’s Signature:

________________________________________ Date: ____________________

I have kept a copy of this completed form for my records.

Student Signature: ______________________________________

Cds Form - Niagara College Page 2

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