Fillable Columbia University Measles, Mumps, and Rubella Form (Columbia University)

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Columbia University Measles, Mumps, and Rubella Form (Columbia University)

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I. STUDENTS COMPLETE THIS SECTION
New York State Public Health Law 2165 and University Policy REQUIRES all students born on or after
JANUARY 1, 1957 prove immunity to Measles, Mumps, and Rubella.
Student Name: _______________________________ _________________________________________ _______
Last/Family First Middle Initial
Columbia ID (PID or UNI): _________________ Birth Date: _____/ _____ / _____ Phone #: _____________________
Personal ID or University Network ID Month Day Year
Personal E-mail: ______________________________ CU School Affiliation: ______________________________
Month Day Year
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Month Day Year
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Month Day Year
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Month Day Year
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The information on this form is accurate to the best of my knowledge.
___________________________________________________________________________________________________________________
Physician/Provider Name (Please Print) Signature
____________________________________________________________________________________________________________________
Physician/Provider Stamp Lic. #
II.
HEALTH CARE PROVIDERS COMPLETE THIS SECTION
All of section A or section B below must be completed by a physician or health care provider.
Section A: MMR (Measles, Mumps, and Rubella)
_____ 1st MMR DOSE: Administered after the rst birthday AND after 1/1/1972
and
_____ 2nd MMR DOSE: or 2nd Live Virus Measles Dose:
Administered at least 28 days after 1st dose
Section B-PART 1: MEASLES
_____ 1st Live Virus Dose: Administered after rst birthday
and
_____ 2nd Live Virus Dose: Administered at least 28 days after 1st dose
or
_____ History of Illness documented by Health Care Provider
or
_____ Immunity Proven by Serologic Testing – MUST SUBMIT COPY OF LAB REPORT
Section B-PART 2: MUMPS
_____ Live Virus Dose: Administered after first birthday AND after 1/1/1969
or
_____ History of Illness documented by Health Care Provider
or
_____ Immunity Proven by Serologic Testing – MUST SUBMIT COPY OF LAB REPORT
Section B-PART 3: RUBELLA (German Measles)
_____ Live Virus Dose: Administered after first birthday AND after 1/1/1969
or
_____ Immunity Proven by Serologic Testing – MUST SUBMIT COPY OF LAB REPORT
Note: History of Illness is NOT acceptable
COURSE REGISTRATION IS PROHIBITED UNTIL COMPLETE DOCUMENTATION HAS BEEN RECEIVED & PROCESSED.
DOCUMENTATION IS DUE UPON ADMISSION OR AT LEAST 30 DAYS BEFORE REGISTRATION.
Columbia University Measles, Mumps, and Rubella Form
Please upload the completed to form via the secure Patient Portal (secure.health.columbia.edu).
Alternately you may submit via fax (212-854-5078); mail/in person to Columbia Health Immunization Compliance Office at John Jay Hall, 3rd Floor,
519 W. 114th Street, Mail Code 3601, New York, NY 10027; or email to immunizationcompliance@columbia.edu.
Please note that communications sent via email over the Internet are not necessarily secure. Columbia University cannot guarantee that the information and
records submitted via unencrypted email will not be intercepted and read by other parties besides the University.
OR
By checking this box and typing my name above, I am electronically signing this form
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Measles, Mumps, and Rubella Form Instructions and Explanations
Instructions
Students: Complete the top portion of this form. Once your physician or health care provider has
completed this form or you have copies of supporting documentation, make a copy for your records and
return the originals to the Immunization Compliance Office via the options at the top of the form. We will be
unable to process your form without your name, birth date, health care provider’s name, and provider’s
signature.
Physician or other Health Care Provider: Complete all required information. Documentation of two
(2) MMR vaccines (or equivalent) is required: the first administered after the first birthday and the
second administered at least 28 days after the first vaccine. Laboratory results with results and reference
ranges must be provided if immunity is demonstrated by serological testing. If there is no supporting
documentation, this form will NOT be processed without a health care provider’s name and signature.
Explanations of Supporting Documentation
1.
2.
3.
4.
health.columbia.edu/immunization
COURSE REGISTRATION IS PROHIBITED UNTIL COMPLETE DOCUMENTATION HAS BEEN RECEIVED.
DOCUMENTATION IS DUE UPON ADMISSION OR AT LEAST 30 DAYS BEFORE REGISTRATION.
Immunization Documentation from Another School
Students who have attended another school in the United States may submit a copy of those immunization
records to prove immunity to measles, mumps, and rubella. Once you have obtained a copy of your
documentation, please complete the top portion of this form and attach to the copy of your immunization
record. Since requirements vary by state and country, your record is reviewed for compliance with New
York State and University requirements. It is important for you to maintain a copy, as the forms are often
illegible or lack identifying information required to process the documentation.
Vaccine History
Provide a certificate of immunization verifying the date of the disease, or the administered measles,
mumps, and rubella vaccines. This includes documents such as:
•
A certificate from a licensed physician
•
A migrant health record
•
A community health plan record
•
An immunization record card signed by a physician, a physician’s assistant, or nurse practitioner
You must also complete the student section of this form and submit it along with your immunization
record. Please note that all immunizations must have been received after your first birthday.
Document History of Illness
If you have been diagnosed by a physician with having had measles or mumps, this is acceptable proof of
immunity. The physician must enter the dates of initial diagnosis on this record form. Note: A diagnosis of
previous rubella disease is not acceptable proof of immunity under New York State Health Code.
Immunity Proven by Serological Testing
Immunity to all of the three diseases may be proven by blood test for antibodies. You must submit the
actual laboratory report with results and reference ranges mif immunity is demonstrated by serological
testing.
If you have any questions please email immunizationcompliance@columbia.edu. Please retain
a copy for your records.
May 2019
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Columbia University Measles, Mumps, and Rubella Form (Columbia University)

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Completed 10 June 2021

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