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Immunization Form-2023

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33 views

Immunization Form-2023

Uploaded by

sonidave06
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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IMMUNIZATION RECORD

Immunization records are required prior to registration


Please complete this form and return it to Health Services 524 W59th Street, Room L68.00NB, New York NY 10019, or fax to 212-237-8026

Document must be legible to be processed. Students are responsible for obtaining an official translation of foreign records prior to
submission.*Students born prior to January 1, 1957 are exempt from the measles, mumps, and rubella requirement. All students
registering for 6 credits or more (or its equivalent) must also complete Part 3 - Meningococcal Vaccination Response on reverse side.

Part 1: Student Information -- To be completed by the student --

Name (please print)_______________________________________________________________________________________


Last name First name Middle Initial
Date of Birth EMPL ID # Daytime phone Mailing Address
____/____/____ __ __ __ __ __ __ __ __ ( )________________ ____________________________
mm dd yyyy

Information to Complete Immunization Requirements


Measles, Mumps, Rubella:
New York State Public Health Law 2165 requires all students entering a post-secondary institution to provide their health services center
with proof of immunity to measles, mumps and rubella. This law applies to students born on or after January 1, 1957, who are registered
for 6 or more credits (or its equivalent) regardless of degree or non-degree status at a CUNY campus.

ACCEPTABLE PROOF OF IMMUNITY MAY INCLUDE:


(1) Immunization cards from childhood (yellow card), signed and stamped.
(2) Immunization records from college, high school or other schools you attended.
(3) Signed and stamped immunization record from your health care provider or clinic. Note: Immunization records obtained from a public
health department immunization information system. Students born after 1994 who were raised in New York City can check the Citywide
Immunization Registry for their records by calling 311.
(4) Copy of lab report, (also known as titer or serology), showing immunity to measles, mumps and rubella.
(5) Proof of honorable discharge from the armed services within 10 years from the date of application will enable the student to attend
school pending actual receipt of the immunization records from the armed services.

**If you attended a CUNY college, your immunization record will be available at your new school**
Part 2: Immunization History -- To be completed by a health care provider -- *Documentation must be included*

Provider: All dates must include month, day, and year. Please mark an (X) in the appropriate boxes
Measles, mumps and rubella must be live vaccine and given no more than 4 days prior
A. to first birthday. month day year
MMR (measles, mumps, rubella) – if given as combined dose instead of individual vaccine.
 Dose 1: No more than 4 days prior to first birthday, AND on or after January 1, 1972
 Dose 2: At least 28 days after 1st vaccine
 Measles (Rubeola) Dose 1: Immunized on or after Jan. 1, 1968 and first birthday AND

O  Measles (Rubeola) Dose 2: Immunized at least 28 days after the first dose
R  Rubella Immunized after 1969 and on or after first birthday
 Mumps Immunized after 1968 and on or after first birthday

month day year


Titer (blood test) showing positive immunity (Dated lab results MUST be attached)
O
 Measles
R
 Mumps
 Rubella
Health care provider information: (Please include official stamp)

B. Name:____________________________________________ Address: __________________________________________

Signature: _________________________________License #:______________________Phone :( )_________________


New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester hours or the
equivalent per semester, or at least four (4) semester hours per quarter, complete and return the following form to 524 W59th Street, Room
L68.00NB, New York NY.

Part 3: Meningococcal Meningitis To be completed by the student

Instructions: Please check one box in Section A below and sign and date in Section B

A. I have (for students under the age of 18: My child has):

 had meningococcal immunization within the past 5 years. The vaccine record is attached.
 The Advisory Committee on Immunization Practices recommends that all first-year college students up to age 21 years
should have at least 1 dose of Meningococcal ACWY vaccine not more than 5 years before enrollment, preferably on
or after their 16th birthday, and that young adults aged 16 through 23 years may choose to receive the Meningococcal
B vaccine series. College and university students should discuss the Meningococcal B vaccine with a healthcare
provider.
 First-year college students living in residence halls are recommended to be vaccinated with meningococcal conjugate
vaccine. If you received this vaccine before your 16th birthday, you must get a booster dose before going to college for
maximum protection.

 read, or have had explained to me, the information regarding meningococcal disease. I (my child) will obtain
immunization against meningococcal disease within 30 days from my private health care provider or [ENTER NAME
OF COLLEGE HEALTH CENTER OR OTHER HEALTH FACILITY]
_________________________________________________

 read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not
receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal disease.

B. _______________________________________________________________________ _______/________/_________
Student/ Parent Signature if student is under 18 years. mm dd yyyy

How do I get more information about meningococcal disease and vaccination?


 Contact your primary care provider or your Health Services Center at 524 W59th Street, Room L68.00NB, or visit our
website at: http://www.jjay.cuny.edu/student-health-center

Additional information is also available on the following websites:


 www.health.state.ny.us (New York State Department of Health)
 http://www.cdc.gov/vaccines/vpd-vac/ (Centers for Disease Control and Prevention)
 www.acha.org (American College Health Association)

TO SUBMIT IMMUNIZATION RECORDS:


Mail to: Health Services 524 W59th Street, Room L68.00NB, New York NY 10019
Fax to: 212-237-8026
Email: healthoffice@jjay.cuny.edu

Part 4: For Office of Health Services Staff Use Only


Processed by: rec:_____________ ent:_____________

Staff Name:____________________________ Staff Signature: _____________________________ Date:__________________

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