Schenectady County Community College
Student Affairs, Elston Hall 222
78 Washington Avenue
Schenectady, New York 12305
STUDENT IMMUNIZATION RECORD FORM
All students enrolled in six (6) credit hours or more, whose birth date is on or after January 1, 1957, MUST comply
with immunization requirements. Immunization information must be received by Student Affairs, Elston Hall 222 in
person, by mail to the above address, by fax to: 518-381-1456 or sent via email to email@example.com
before the student attends the first class. Please call 518-381-1344 with questions.
Name___________________________________ Date of Birth _______________ Student ID___________________
Semester___________ Year_________ Phone Number________________ Email ____________________________
Required: Two doses of the MMR immunization, given after 12 months of age with the second dose at least one
month after the first dose or blood tests showing immunity to all three illnesses.
Measles (Rubeola) Two doses required: Vaccine Date _________________Vaccine Date___________________
Mumps Vaccine Date ______________ or Disease History____________________________________________
Rubella Vaccine Date ______________ or Disease History____________________________________________
Titer – Results from this test are useful for people who are not sure if they have been vaccinated or need to prove if
they have immunity from prior vaccinations.
Measles (Rubeola) Titer Date _________________ Result______________________________________
Mumps Titer Date _________________ Result ______________________________________
Rubella Titer Date _________________ Result ______________________________________
Required: One dose of the Meningococcal immunization given within the last 5 years; or a complete two dose series
or a signed waiver. New York State Department of Health requires each student to indicate meningitis compliance by
providing a waiver of the vaccine OR providing medical documentation of date of vaccine.
Meningococcal Vaccine for Meningitis Vaccine Date _________________Vaccine Date___________________
WAIVER: I have reviewed the information regarding meningococcal disease. I am fully aware of the risks associated
with this disease and of the availability and effectiveness of the vaccine. I have elected NOT to get the vaccine.
Signature of Student (Parent/Guardian if student is under 18) Date
EARLY CHILDHOOD STUDENTS ONLY: Tuberculin Date_______________
Send result attached to college physical.
Physician Name (Printed)__________________________Signature_________________________Date__________
Address and Phone number:______________________________________________________________________
We accept proof of immunizations from medical offices, schools and universities. If you are providing an immunization report from your doctor’s office, school or university,
it is not necessary to have this form signed or to return this form as long as you have met the MMR and Meningitis requirement.
click to sign
click to edit
click to sign
click to edit