Clinton Community College



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Nicole A. Powers-Allen RN
Student Support Services Nurse

The Health Office is located in Room 149 of the main building. Services available Monday - Friday 8:00 a.m. - 4:00 p.m.

Services Provided:

Immunization Record

Submit this form  to the Health Office PRIOR TO registering for classes.

Name _______________________________ Social Security # (optional) ________________

Address ________________________________________ Date of Birth _______________

New York State Public Health law 2165 now requires post-secondary students to show immunity against Measles (Rubeola), Mumps, and Rubella (German Measles). Persons born prior to January 1, 1957 are exempt from this requirement unless the individual is in a degree program that requires this documentation (i.e. Nursing, MLT). Students taking on-line courses only are also exempt. Meningococcal Meningitis information (below) must also be completed.

REQUIRED: Measles (Rubeola) Immunity—Must have ONE of the following three:

1. TWO dates of *Measles Immunization: (1)_____________and (2)____________________

Both must be given after 1967 and the first shot must be on/after 12 months of age, the second shot must be on/after 15 months of age. (*MMR vaccine recommended for both).

2. Date of Measles Titer:____________________. Results:_________________________

3. Date of Physician’s diagnosis of disease (record must include Physician’s signature) ____________________

REQUIRED: Mumps Immunity—Must have ONE of the following three:

1. Date of one Mumps Immunization: (1)____________________. Must be on/after 12 months of age.

2. Date of Mumps Titer:____________________. Results:_________________________

3. Date of Physician’s diagnosis of disease (record must include Physician’s signature) ________________________________

REQUIRED: Rubella Immunity—Must have ONE of the following two:

1. Date of one Rubella Immunization: (1)_________________. Must be on/after 12 months of age.

2. Date of Rubella Titer:____________________. Results:_________________________

*Physician diagnosis is NOT acceptable for Rubella Immunity.

Doctor’s Name & Practice Name (PRINT):________________________________________

Doctor’s Signature:____________________________________________ Date:_________________________

Meningococcal Meningitis (check one box and sign below, parents must sign if student’s age is under 18).

o I have had the meningococcal meningitis (Menomune or Menactra) immunization within the past 10 years.  Date vaccine administered:____________________.

o I have read, or have had explained to me the information regarding meningococcal meningitis disease and will obtain immunization against meningococcal meningitis within 30 days from my health care provider or the Health Department.

o I have read, or have had explained to me the information regarding meningococcal meningitis disease and understand the risks of not receiving the vaccine. I have decided that I will NOT obtain immunization against meningitis.

Student/Parent Signature:________________________________________ Date:_________________________

RECOMMENDED VACCINES

Date of Tetanus (Td) booster:____________________ (should be every 10 years).

_________________________________________________________________________

Frequently Asked Questions:       

Question:
Answer:		 Where can I obtain my immunization records from?
Contact the high school that you last attended. They may have the necessary information that can be forwarded to our office. If you are an armed service veteran, you may have received the necessary immunizations through the military and can forward a copy of the records to the Records Office for review. Your family doctor may also have this information and can make a copy or fill out the purple student immunization record form.
Question:
Answer:		 What if I have a medical reason why I should not receive the MMR vaccinations?
Your doctor must certify in writing the specific reasons why you should not receive the vaccination and an approximate date on which you will be able to receive the vaccination.
Question:
Answer:		 What if I am unable to locate my immunization records?
Contact your physician, and discuss with him/her the possibility of being re-immunized or of having blood titers drawn.
Question:
Answer:		 What if I can not afford to receive the vaccination?
You should contact your local County Public Health Office. They may offer the MMR vaccination to college students for $10.00 and Meningitis vaccinations for $65.00-$95.00.
Question:
Answer:		 What if my religion prohibits me from receiving the immunization?
You may request an exemption by contacting the Records Office.
Question:
Answer:		 What are the penalties for failure to comply?
You will be prohibited from attending classes if all information is not received in the Records Office within 30 days from the start of classes. A hold will be placed on your account not allowing you to register for future classes at CCC nor will your grades or transcripts be issued until you have complied with New York State Public Health Law.
Question:
Answer:		 Could I be exempt from the MMR Requirement?
You are exempt if you are not in an allied health program, are enrolled for less than six (6) credits and were born before January 1, 1957.