Fillable MANDATORY IMMUNIZATION RECORD VERIFICATION FORM (Monroe College)

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MANDATORY IMMUNIZATION RECORD VERIFICATION FORM (Monroe College)

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OFFICE OF STUDENT HEALTH AND WELLNESS
406 Main Street, New Rochelle, NY 10801 • Office: 914.740.6459 • E-Fax: 914.813.1281 • MyMonroeHealth@monroecollege.edu
MANDATORY IMMUNIZATION RECORD VERIFICATION FORM
NYS Public Health law requires that these forms must be completed in order to attend Monroe College. If you need help
in obtaining these immunizations, contact the Office of Student Health and Wellness at 914.740.6459.
TO BE COMPLETED AND SIGNED BY A HEALTH CARE PROVIDER (Dates must include Month, Day, Year)
Name (Last, First, Middle) ______________________________________________________________________________________
Date of Birth __________________________________________________________________ Age ___________________________
Current Address _______________________________________________________________________________________________
City ______________________________________________________ State ______________ Zip ____________________________
Student Signature _____________________________________________________________ Date __________________________
NEW YORK STATE, PUBLIC HEALTH LAW, CHAPTER 2165 requires all students to provide Monroe College with proof of
immunity to measles, mumps and rubella (MMR). Proof of immunity is defined as 2 doses of measles vaccine and 1 dose
each of rubella and mumps vaccine. The first dose must be no more than 4 days prior to the students first birthday and
the second at least 28 days after the first dose. Acceptable forms of proof include:
1. Childhood immunization records showing the exact dates of your vaccines or
2. Positive blood test for immunity (titers)
3. This form completed by your health care provider, dated, signed and stamped.
MMR (Measles, Mumps, Rubella — Combined) Vaccine _____ /_____ /_____ _____ /_____ /_____
OR
Measles (Rubeola) Immunity: Complete all that apply:
Two doses of live measles vaccine: _____ /_____ /_____ _____ /_____ /_____
Date of immune measles titer & result: _____ /_____ /_____ __________________
Date of physician diagnosed measles disease: _____ /_____ /_____
Mumps Immunity: Complete all that apply:
One dose of mumps vaccine _____ /_____ /_____
Date of immune mumps titer & result: _____ /_____ /_____ __________________
Date of physician diagnosed mumps disease: _____ /_____ /_____
Rubella (German Measles) Immunity: Complete all that apply:
One dose of rubella vaccine: _____ /_____ /_____
Date of immune rubella titer & result: _____ /_____ /_____ __________________
* A Rubella titer is the only permissible evidence that is an alternative to immunization. Rubella rashes resemble rashes
of other diseases and it is impossible to diagnose reliably.
Health Care Provider: ____________________________________ Signature & Stamp: ____________________________________
Date: _____________________________ License # _________________________ Phone # ________________________________
(Parent or Guardian if student is a minor)
MM MMDD DDYYYY YYYY
MM DD YYYY
MM DD YYYY
MM DD YYYY
MM/DD/YYYY
(Mandatory Signature and Stamp)(Please Print)
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OFFICE OF STUDENT HEALTH AND WELLNESS
406 Main Street, New Rochelle, NY 10801 • Office: 914.740.6459 • E-Fax: 914.813.1281 • MyMonroeHealth@monroecollege.edu
MENINGITIS INFORMATION
New York State Public Health Law 2167 requires all post secondary institutions to distribute information about meningococcal
meningitis and meningitis immunization to all students. Meningitis is rare. However, when it strikes, its flu-like symptoms make
diagnosis difficult. If not treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal column as
well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation and even death.
Cases of meningitis among teens and young adults 15-24 years of age (the age of most college students) have more than
doubled since 1991. The disease strikes about 3,000 Americans each year and claims about 300 lives. Between 100 and 125
meningitis cases on college campuses and as many as 15 students will die from the disease.
A vaccine is available that protects against four types of the bacteria that cause meningitis in the United States- types A, C,
Y, and W-135. These types account for nearly two thirds of meningitis cases among college students. If you wish to obtain a
vaccination against this disease, contact your physician for availability and cost. The vaccine is available in New Rochelle for an
estimated cost of $100.00.
Monroe College is required to have the following document completed and on file:
MENINGOCOCCAL MENINGITIS RESPONSE
TO BE COMPLETED AND SIGNED BY THE STUDENT OR PARENT/GUARDIAN IF STUDENT IS A MINOR:
Check one box and sign below:
I (my child) have had the meningococcal meningitis immunization within the past 10 years.
Date received: _____ /_____ /_____
I have read, or have had explained to me, the information regarding meningococcal meningitis disease.
I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization
against meningococcal meningitis disease.
Student Signature _________________________________________ Date _______________________________________________
Parent / Guardian Signature ________________________________ Relationship to Student ______________________________
MM DD YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
(Mandatory Signature and Stamp)
(Under 18)
(Under 18)
(Please Print)
Health Care Provider: _______________________________________ Signature & Stamp: _________________________________
Date: ___________________ License # _________________________ Phone # ___________________________________________
AUTHORIZATION FOR TREATMENT FROM MONROE COLLEGE HEALTH SERVICES
The undersigned patient and/or responsible relative or person, hereby consents to and authorizes Monroe College Office of
Student Health and Wellness clinicians, Monroe College Sports Medicine Department clinicians, and medical personnel to admin-
ister or perform any and all medical examinations, treatments, designated procedures, vaccinations, and immunizations against
diseases or injuries which may be now or during the course of care deemed necessary or advisable.
Student Name ____________________________________________ Date ________________________________________________
Student Signature __________________________________________ Parent / Guardian Signature ___________________________
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MANDATORY IMMUNIZATION RECORD VERIFICATION FORM (Monroe College)

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Completed 21 July 2020

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