OFFICE OF THE REGISTRAR
California State University, Chico
STUDENT IMMUNIZATION CERTIFICATION
NAME
(Please Print):______________________________________________________________________________________________
Last First MI
STUDENT ID: ________________________________________ DATE OF BIRTH: ________________________________
(Mo) (Day) (Yr)
General Information
If either the Measles/Rubella and/or the Hepatitis B requirement below apply to you, please review your personal immunization record and complete
this form. If you do not have an immunization record, you may be able to obtain a copy from your high school, physician, or health department. If
your record indicates that you need an immunization(s), take this form and any immunization records you may have to your doctor, local health
department or the campus Student Health Center. The doctor or nurse will review your history and give you any needed immunization(s). Failure to
comply with the university’s immunization requirement will result in denial of future registrations.
IMMUNIZATIONS (proof of completed immunizations must be attached)
Measles (Rubella) and Rubella (German Measles)
The California State University requires all new students born after January 1, l957 to present proof of measles and rubella immunizations. You must
submit proof of measles and rubella immunizations by your second semester of enrollment at the University.
Hepatitis B
If you are 18 years old or younger on the first day of classes of your first semester at CSU Chico, you are required to meet the three-shot Hepatitis B
immunization requirement. Even if you turn 19 years of age during your first year of enrollment at the University, you are responsible for
completing the Hepatitis B immunization requirement. You must submit proof of full immunization by the end of your second semester of enrollment
at the University. To comply with this requirement, you must provide proof of completion of the third shot in the three shot Hepatitis B series.
IMMUNIZATION DATES:
Measles/Rubella and/or Hepatitis B Immunizations may be submitted on the same or two separate immunization forms.
Measles: _____________________ Rubella: ______________________
(Mo) (Day) (Yr) (Mo) (Day) (Yr)
Hepatitis B (3-shot series): ____________ ____________ ___________
(Mo) (Day) (Yr) (Mo) (Day) (Yr) (Mo) (Day) (Yr)
EXEMPTION FROM IMMUNIZATION: To request exemption, check the item which applies to you and attach any required
proof.
California Public
School [NOCER]: Proof of enrollment in a California public school for the seventh grade or higher
on or after July 1, l999. A copy of a California transcript/academic record must be
attached to this form.
Laboratory Verification [MEDX]: Based on written verification of laboratory-confirmed measles, rubella, or both, and/or
hepatitis B. The verification(s) must be sign
ed by a physician and a copy must be attached to this form.
Temporary Exemption – Distance Stu
dents Only [NOCER)]: Based on verification that the student’s classes are online/off-campus
workshops only. Students checking this option must request exemption each semester of attendance.
If you select either of the following exemptions and there is an outbreak, you may be asked to leave the campus:
Medical Exemption [MEDX]: Based on a letter or note from a physician indicating the reason for the exemption(s). The
letter
or note must be signed by the physician,
and a copy must be attached to this form.
Religious or Personal Beliefs [P/REX)]: “I request exemption from the measles and rubella immunization requirements and/
or h
epatitis B requirement because they are contrary to my religious or personal beliefs.”
I CERTIFY THAT THE INFORMATION ENTERED ABOVE IS TRUTHFUL AND ACCURATE AND I HAVE ATTACHED A COPY OF THE
DOCUMENT(S) WHICH VERIFIES MY IMMUNIZATION OR EXEMPTION STATUS:
Student Signature: _________________________________________________________________ Date:_________________
(If under age 18, parent or guardian must also sign)
Return this form
to
:
02/14
Office of the Registrar
California State University, Chico
Chico, CA 95
929- 0720
530- 898-5142
FAX: 530-898-4359
For Office Use Only
MEAS=Measles RUBL=Rubella
HEPB= Hepatitis
