Office of the Registrar - Cape Cod Community College - Student Immunization Records
2240 Iyannough Road, West Barnstable, MA 02668
774-330-4331 / Fax 508-375-4039 /
sthompson@capecod.edu
Immunization Records Request Form
HEALTH RECORD RETENTION POLICY: All students are encouraged to establish a personal file for
their medical records. Immunization documents are retained by the college for five (5) years only and
then destroyed.
Requests will be processed within 10 business days.
Last Name:
First Name:
Student ID #:
Other/Maiden Name(s) :
Date of Birth: (mm/dd/yyyy)
SSN:
Phone: Dates of Attendance:
Address: City:
State:
Zip:
Check all that apply :
□ I will pick up a copy of my immunization records. Please call me when they are ready at the number listed above.
□ Please mail a copy of my immunization records to my address listed above.
□ Please fax a copy of my immunization records to:
Name and Number:
□ Please forward a copy of my immunization records to:
Student Signature:
Date:
FOR OFFICE USE ONLY:
RCVD’: INTIALS:
This fax/e-mail, including any attachments, may be intended solely for the personal and confidential use of the sender and
recipient (s) named above. This message may include advisory, consultative and/or deliberative material and, as such, would be
privileged and confidential under HIPAA regulations and not a public document. Any information in this fax/e-mail identifying a
student of Cape Cod Community College is confidential. If you have received this fax/e-mail in error, you must not review,
transmit, convert to hard copy, copy, use or disseminate this fax/e-mail or any attachments to it and you must delete this
message. You are requested to notify the sender by return e-mail. Thank you.
**THIS INFORMATION IS PRIVATE & CONFIDENTIAL*
4/2/12 slg 2/2/18 st
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