Immunization Record Form - Columbia-Greene Community College
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1IMMUNIZATION RECORD
COLUMBIA-GREENE COMMUNITY COLLEGE
N
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S
ID N
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AME
TUDENT
UMBER
A
:
D
B
:
DDRESS
ATE OF
IRTH
S
:
EMESTER AND YEAR OF ENTRY
(P
)
LEASE FILL IN DATE BELOW
T
N
.:
F
S
S
ELEPHONE
O
ALL
PRING
UMMER
YEAR
YEAR
YEAR
New York Public Health Law 2165 requires all post-secondary students born on or after January 1, 1957 to show
immunity against measles, mumps, and rubella before registering for classes. Certain medical and religious factors may
qualify a student for an exemption from this requirement.
IMMUNIZATIONS
(exact dates must be listed)
Disease
Vaccine Date
Disease History
Serology (Blood Titer)
Month/Day/Year
(Onset Date) must include
Date
signature of diagnosing
(Attach Copy of
physician
Lab Report)
MEASLES* +
2 required
Given after 1967
RUBELLA*
Given after 1968
MUMPS*
Given after 1968
or
combined
as
MMR +
*New York State law requires that the above immunizations must have been given not more than four days before your first birthday.
+There must be an interval of at least 28 days between the first and second doses of measles vaccine.
Additional vaccines and testing recommended by NYS Department of Health:
Hepatitis B
Serology
(Attach copy of Lab Report)
Tetanus Booster (within ten years)
Meningococcal Meningitis
Varicella (Chicken Pox)
Serology
_
_______________
(Attach Copy of Lab Report)
PPD (Mantoux) Test
mm induration
(date placed)
(date read)
(results)
Please include month, day, and year for all immunizations.
HEALTH CARE PROVIDER
Name
Address
Signature
Date
Phone
Return form to:
Director of Health Services, Columbia-Greene Community College
4400 ROUTE 23, Hudson, New York 12534
518-828-4181, ext. 3202
FAX 518-751-2101
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