Certificate Of Immunization - Health Services printable pdf download

CERTIFICATE OF IMMUNIZATION

Name_____________________________________________ Birth Date_________/____________/___________

Address________________________________________________________________ Res Hall Student Y or N (circle one)

Phone No. (_____)_____________________________ SS#/ID#________________________________

New York Public Health Law requires all students born after 1956 and enrolling for 6 credit hours or more to prove immunity to measles, mumps, and

rubella. All immunizations must be administered after 1967, on or after the first birthday, and a minimum of 30 days apart. Exceptions to this

requirement will be made for students with genuine and sincere religious beliefs contrary to immunization or for those whom immunizations are

medically contraindicated.

Proof of Immunity

2 measles, 1 mumps and 1 rubella immunization OR serology demonstrating proof of immunity to measles, mumps and rubella, OR history of disease

(must have date) for measles and mumps signed by a physician. History of rubella is not acceptable.

MANDATORY:

IMMUNIZATIONS

SEROLOGY

MMR date 1 ________________ date 2 _______________

Measles date_______________ Result (Pos/Neg)________________

Measles date 1_______________ date 2 _______________

Mumps date________________ Result (Pos/Neg)_______________

Mumps date ________________ Rubella date______________

Rubella date________________ Result (Pos/Neg)________________

HISTORY OF DISEASE please list date of illness

( ) Measles _____________________ ( ) Mumps ______________________

Signature of Physician____________________________________________________________________________

MENINGITIS

*Meningitis Vaccination Date_______________________

I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the

vaccine. I have decided that I or my child (if under 18 yrs of age) will not obtain the immunization against the meningitis disease.

Signature______________________________________________________________ Date_________________________________

*New York Public Health Law requires all college students enrolled for 6 credit hours or more be provided with information on meningitis and the

meningitis vaccine and either provide proof of receiving the meningitis vaccine within the last 10 years or decline the immunization.

RECOMMENDED:

Tetanus Date __________________ (within 10 years)

Hepatitis B Date #1 ________________ Date #2 _______________Date #3 ____________ or Serology Date ____________ Result (Pos/Neg)________

Tuberculosis (PPD) Date ________________ Result _______ X-Ray Date (if positive) ______________ Result (Pos/Neg) __________

Varicella Vaccine Date ______________ Disease Date ______________ or Serology Date _______________ Result (Pos/Neg) __________

SIGNATURE OF HEALTH CARE PROVIDER completing form:

_________________________________________________________________ Date ________________________

This form must be completed and returned to Health Services or students will be restricted from future registration or receiving of grades.

Health Services, 1000 East Henrietta Rd., Rochester, NY 14623 (585) 292-3856 (fax); (585) 292-2018 (ph)

Rev. 4/14

Certificate Of Immunization - Health Services