Fillable MCC Registrar's Office Immunization Verification Form

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MCC Registrar's Office Immunization Verification Form

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OPTION 2: RECORD OF IMMUNIZATION
IF YOU ARE NOT EXEMPT, PLEASE COMPLETE ONE OF THE OPTIONS BELOW AND ATTACH THE NECESSARY DOCUMENTATION.
STUDENT INFORMATION
PHYSICIAN SIGNATURE
Registrar’s Office
Immunization Verification
OPTION 1: LAB EVIDENCE OF IMMUNITY OR CONFIRMED CASE OF DISEASE
First Name MI Last Name
Social Security Number Date of Birth Banner ID Number
Test results (Titer) for lab evidence must be attached to this form or document that you have already had the disease(s). If you cannot document a confirmed case of the disease(s), then you
must submit immunity results form a medical laboratory.
I hereby certify that this student has received the immunization(s) or has laboratory evidence of immunity as indicated.
Please fax completed form to 860-512-3221 or email it to Sherri Scudder at sscudder@manchestercc.edu. For questions, please call 860-512-3225.
STUDENTS MUST RETURN THIS COMPLETED DOCUMENT TO THE REGISTRAR’S OFFICE PRIOR TO REGISTRATION.
Mailing Address
City State Zip
Physician Signature or Authorized Person Date
Physician’s Stamp or DEA Number
Vaccination Type Date of Test Result of Test Date of Disease
Month/Date/Year
Month/Date/Year Month/Date/Year
Month/Date/Year Month/Date/Year Titer Date or History of Disease
MEASLES
MUMPS
RUBELLA
VARICELLA
MMR
VARICELLA
and
August 2017/PR
STATE IMMUNIZATION POLICY
Connecticut State Law requires that all full-time and part-time matriculating students born after December 31, 1956 and enrolled in postsecondary schools be
adequately protected against measles, mumps, rubella and varicella (chickenpox). Students must have two doses of each vaccine administered at least one month
apart to ensure adequate immunization.
TO BE COMPLETED BY PHYSICIAN.
Page 2: Immunization Waivers
Options 3 and 4: Medical or Religious Exemptions
August 2017/PR
OPTION 3: MEDICAL EXEMPTION
OPTION 4: RELIGIOUS EXEMPTION
EXEMPTIONS
Students with medical or religious exemptions shall be permitted to attend college except in the case of a vaccine-preventable disease outbreak in the college. All
susceptible students will be excluded from college based on public health officials’ determination that the college is a primary site for disease exposure, transmis-
sion and spread into the community. Students excluded from college for this reason will not be able to return to school until:
1. The danger of the outbreak has passed as determined by public health officials
2. The student becomes ill with the disease and completely recovers, or
3. The student is immunized.
For example, for measles, the complete incubation period is 18 days from the onset of symptoms for the last case in the community. Outbreaks like measles may
last for several months.
According to Connecticut General Statues Sections 19a7f and 10-204a, no student may be admitted to school without proof of immunization or a statement of
exemption. Students seeking an exemption on the basis that a given immunization is medically contraindicated should attach a statement to the form signed by
their physician stating that in the physician’s opinion, such immunization is medically contraindicated and why it is contraindicated (ex. hypersensitivity to a vaccine
component, demonstrated reaction to vaccine etc.) In addition, the students should complete the following statement and return it to the Registrar’s Office.
Student Name MI Last Name
Student Name MI Last Name
Student Signature Date
Student Signature Date
I am submitting the enclosed documentation from a physician that immunization is medically contraindicated. Therefore, I am exempt from receiving the
required immunization as specified by the physician, and shall be permitted to attend college except in the case of a vaccine-preventable disease outbreak in
the school.
I hereby assert that immunizations would be contrary to my religious beliefs. Therefore, I am exempt from receiving the required immunization under
Section 10-201a of the Connecticut General Statutes and shall be permitted to attend college except in the case of a vaccine-preventable disease outbreak in
the school.
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MCC Registrar's Office Immunization Verification Form

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Completed 25 July 2020

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