Medical Requirements Form printable pdf download

MEDICAL REQUIREMENTS

Meningitis Response Signature (Part 1) and MMR Immunization Records (Part 2)

are required before registration

Name: ___________________________________________________ SSN#:__________________________

Address: _________________________________________________________________________________

Phone: (____) ________________________

DOB: ______________________

Part 1- TO BE COMPLETED AND SIGNED BY STUDENT OR PARENT/GUARDIAN FOR STUDENT UNDER THE AGE OF

MENINGOCOCCAL MENINGITIS.

CHECK ONE (1) BOX ONLY (One dose within 10 years recommended by NYSPHL2167)

□

I have read, (see reverse side) or have had explained to me, the infromation regarding meningococcal meningitis.

The vaccination was administered on

DATE____/_____/_____

□

I have read, (see reverse side) or have had explained to me, the information regarding meningococcal meningitis.

I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against

meningococcal meningitis.

*For Meningitis Vaccine availability, check with your primary care physicain OR visit the CDC Travel Clinics

websites: The cost approximately $100

Signed: _______________________________________

Date:______________________

Part 2 - TO BE COMPLETED, SIGNED, AND STAMPED BY YOUR HEALTH CARE PROVIDER.

Single immunizations (one mumps, one measles, or one rubella) must have been given after January 1, 1968.

Measles 1 Date___/____/____

Measles 2 Date: ___/___/_____

Mumps

Date___/____/____

Rubella Date: ___/___/_____

M.M.R. (Measles, Mumps, Rubella) (Two doses; after 1/1/1973)

Dose 1 given at age 12 months or later………………………………

Date: ____/____/____

Second dose given after 15 months of age…………………………..

Date: ____/____/____

Laboratory Report proving immunity must be submitted. (MMR Titer)

(See reverse side for information)

I certify that the above-named student has received the above immunizations, or I have enclosed

laboratory results indicating immunity.

Physician signature AND stamp required _________________________________________________

Address: ___________________________________________________________________________

Date: ___/___/____

Phone#: (____) _________________

Return form to: Lehman College Student Health Center, Building T-3 Room 118

250 Bedford Park Blvd. West Bronx, NY 10467 - Telephone: (718) 960-8900 - Fax: (718) 960-8909

Medical Requirements Form