IMMUNIZATION FORM
Must be supplied by your Health Care Provider, your High School, former College/University, or other authorized agency
PLEASE NOTE: Students will not be allowed to register for courses until this form has been completed
and all required documentation has been received.
Date _______________________ Student ID # _____________________
Name (FIRST)________________ (LAST) _________________________
Gender Male Female
Student Status (Check one):
U.S. Citizen Permanent Resident International
Birth date (MM/DD/YYYY) ____/______/_______
Address ______________________________________________
Phone: _________________________________________(cell/home/work)
______________________________________________
Email:___________________________________________________
Hudson County Community College
Office of Enrollment Services
70 Sip Ave, Jersey City, NJ 07306
Date Rec’d: _______________________________
Staff Initials: ______________________________
Immunized Waiver
STATE IMMUNIZATION REQUIREMENTS: (MMR I,II, HEP B, MenACWY)
MMR- 1 Dose; Measles Booster or 2nd MMR; Hepatitis B (full series)
Dates MMR1: _____/______/______ MMR 2: _____/______/____
MEASLES 1: _____/______/______ MEASLES 2: _____/______/______
MUMPS 1: _____/______/____ RUBELLA 1: _____/______/____
HEPATITIS B: _____/______/____
MEASLES SEROLOGY: _____/______/____ TITER: _____/______/____
RUBELLA SEROLOGY: _____/______/____ TITER: _____/______/____
MUMPS SEROLOGY: _____/______/____ TITER: _____/______/____
Meningococcal ACWY MenACWY _____/_____/______
Dose 1: ______/______/______
Dose 2: _____/_______/______
BLOOD TESTS proving immunity to Measles, Mumps, Rubella and Hepatitis B ATTACH COPY OF LAB
RESULTS (please note that a positive result indicates immunity due to vaccination or recovery from an
infection)
Printed Name of Health Care Provider (MD, NP, RN):
Signature of Provider: _________________________________________
Title: _______________________________________________________
Date: ____________________________________
Address: ________________________________________________
Phone: _______________________________________________
EXEMPTIONS FOR MMR and HEP B IMMUNIZATION
Age Exemption: Born prior to January 1, 1957: attach copy of birth certificate (Does not apply to
Hepatitis B)
Religious Exemption: Attach letter from accredited religious leader of your church or religious
institute
Medical Exemption: Signed Physician’s statement explaining why you cannot be immunized
Immune Status (Measles, Mumps antibody, Rubella titers and Hepatitis B) Laboratory blood
results showing level of immunity.
Return your completed Immunization Record to: Hudson County Community College, Enrollment
Services 70 Sip Avenue, Jersey City, NJ 07306 or email it to admissions@hccc.edu
.
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What you need to know about Meningitis
What is Meningococcal Meningitis? Meningococcal disease is a serious bacterial illness. It is a leading
cause of bacterial meningitis in children 2 through 18 years old in the United States. Meningitis is an
infection of the fluid surrounding the brain and spinal cord. Meningococcal disease also causes blood
infections. About 1,000-2,600 people get meningococcal disease each year in the U.S Even when they
are treated with antibiotics, 10-15% of these people die. Of those who survive, another 11-19% lose
their arms or legs, become deaf, have problems with their nervous systems, become mentally retarded,
or suffer seizures or strokes.
Who is at risk? Anyone can get meningococcal disease, but it is most common in infants less than one
year of age and people with certain medical conditions, such as lack of a spleen. College students who
live on-campus and teenagers 15-19 have increased risk of getting meningococcal disease.
How is it spread? Meningococcal meningitis is spread through the air via respiratory secretions or close
contact with an affected person. This can include coughing, sneezing, kissing or sharing items like
utensils, cigarettes and drinking glasses
WHAT YOU NEED TO KNOW ABOUT THE MEMINGOCOCCAL MENINGITIS VACCINE
There are two kinds of meningococcal vaccine in the U.S.:
Meningococcal conjugate vaccine (MCV4) and Meningococcal polysaccharide vaccines (MPSV4)
Both vaccines can prevent 4 types of meningococcal disease, including 2 of the 3 types most common in
the United States and a type that causes epidemics in Africa. Meningococcal vaccines cannot prevent all
types of the disease. But they do protect many people who might become sick if they didn’t get the
vaccine. Both vaccines work well, and protect about 90% of people who get them.
Want more information? To find out more about Meningococcal disease, your vaccines, who should not
get the meningococcal vaccine, and the risks of the vaccine, contact your doctor or nurse, call local or
state health departments or contact the Center for Disease Control Prevention (www.cdc.gov/vaccines)
What is acceptable evidence of vaccination?
Listed below are the acceptable forms of evidence a student may use to submit to the institution. The
documentation must be in English, state the name and other information sufficient to identify the
individual who received the required vaccination, state the month, date and year the required vaccine
was administered.
A. A statement provided by physician or other health care provider authorized by law to administer the
required Vaccine. The statement must include the name, address, signature or stamp, state of licensure
and license number of the physician or other healthcare provider who administered the required
vaccination; or of the public health official who administered the required vaccination.
B. An official immunization record generated from the state or local health authority.
C. An official record received directly from a New Jersey school official, or a school official in another
state.
Local Healthcare Provider Offering HCCC Required Immunizations:
Name
Location
Telephone
Number
Information
Metropolitan
Family
Center
935
Garfield
Avenue
Jersey
City, NJ
07087
201-478-
5800
8:30AM-
3:30PM
No appointment needed
Sliding Scale: Income