Form Cdphe-Imm Ci-C Rc Certificate Of Immunization For College/university Students - Colorado Department Of Public Health & Environment
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1
2CERTIFICATE OF IMMUNIZATION FOR
COLLEGE/UNIVERSITY STUDENTS
Colorado law requires this form be completed by the school.
Please submit your Immunization Record to the school.
Name:
Date of Birth:
Student ID:
Street Address:
City, State, ZIP Code:
School Name:
School Address:
School Phone Number:
School Fax Number:
Immunization requirements for Colorado college students: 2 doses of MEASLES, MUMPS & RUBELLA vaccine.
REQUIRED VACCINE
DATE(S) GIVEN
REQUIRED VACCINE
DATE(S) GIVEN
MMR #1
MMR #2
(Measles-Mumps-Rubella)
(Measles-Mumps-Rubella)
1
1
Measles
Rubella
1
1
Mumps
Meningococcal
1
2
1. Measles, mumps, and rubella (MMR) vaccine is not required for college students born before January 1, 1957. In lieu of immunization, written evidence of laboratory tests
showing immunity to measles, mumps, and rubella is acceptable. Send written proof of lab immunity to the school. The first MMR cannot be accepted by the institute if it was
given more than four days before the 1st birthday. The second dose of MMR must be given at least 28 days after the first dose of MMR.
2. A Meningococcal vaccine, given within the last 5 years, waives the requirement for a new student living in student housing to read and sign the “Information Regarding
MENINGOCOCCAL DISEASE” education document on the reverse side of this Certificiate of Immunization.
The following vaccines are strongly recommended for college students, although not required by Colorado law.
ADDITIONAL VACCINES
DATES GIVEN
ADDITIONAL VACCINES
DATES GIVEN
RECOMMENDED
(IF AVAILABLE)
RECOMMENDED
(IF AVAILABLE)
DTP/DTaP/Tdap
Varicella
(Chickenpox)
(Diphtheria-Tetanus-Pertussis)
Td
HPV
(Tetanus-Diphtheria)
(Human Papillomavirus)
OPV/IPV
Other:
(Polio)
Hep B
Other:
(Hepatitis B)
Hep A
Other:
(Hepatitis A)
TO THE BEST OF MY KNOWLEDGE, THE PERSON NAMED ABOVE HAS RECEIVED THE IMMUNIZATIONS REQUIRED FOR COLLEGE ENTRY
S I G N O N LY W H E N C O L L E G E I M M U N I Z AT I O N R E Q U I R E M E N T S H AV E B E E N M E T
Signed ____________________________________________
Title ______________________________
Date ____________
(Physician, nurse or school health authority)
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW
(DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN)
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.
SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE
LA ESCUELA.
MEDICAL EXEMPTION:
The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated due to
other medical conditions.
EXENCIÓN POR RAZONES MÉDICAS:
El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; o bien, las vacunas están
contraindicadas debido a otros problemas de salud.
Medical exemption to the following vaccine(s):
La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s):
Signed
__________________________________________
Date
___________
________________________________________________________
(Firma)
(Fecha)
Physician (Médico)
RELIGIOUS EXEMPTION:
Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed to immunizations.
EXENCIÓN POR MOTIVOS RELIGIOSOS:
El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización.
Religious exemption to the following vaccine(s):
Exención por motivos religiosos de la(s) siguiente(s) vacuna(s):
Signed
__________________________________________
Date
___________
________________________________________________________
(Firma)
(Fecha)
Parent, guardian, emancipated student or student 18 years and older
(Padre, tutor, estudiante emancipado o estudiante de 18 años y mayor)
PERSONAL EXEMPTION:
Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed to immunizations.
EXENCIÓN POR CREENCIAS PERSONALES:
Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se oponen a la inmunización.
Personal exemption to the following vaccine(s):
Exención por creencias personales de la(s) siguiente(s) vacuna(s):
Signed
__________________________________________
Date
___________
________________________________________________________
(Firma)
(Fecha)
Parent, guardian, emancipated student or student 18 years and older
Form Apprvd. 11/03
CDPHE-IMM CI-C RC Rev. 2/16
(Padre, tutor, estudiante emancipado o estudiante de 18 años y mayor)
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