Immunization Record Front Page MMR/Meningitis Form

[Pages:2]Immunization Record

ImmunMizMatiRon/MReeconridns garietirsequFiroerdmprior to Registration

Front Page

(KEEP A COPY FOR YOUR RECORDS) NBCanCne-IrDID#: N __ __ __ __ __ __ __ __

Name ________________________________________________________________________

Last

First

Address ________________________________________________________________________

Student Health Services

Student Health Office

________________________________________________________________________

TownState Zip Code

Phone ( )__________________ Semester ___________ Date of Birth ____/____/____

*MMR (HEALTH CARE PROVIDER TO COMPLETE BELOW) PART 1 - MENING1IsTt SIhSoSt urvey - Mening2itnidsSvhaoctcination is not mDainsedaasteeDda; theowever, comTpitlreetiDonatoef the survey TisitrreeqRueisrueldt.

Meningococcal Meningitis - Note that vaccine dates are ONLY acceptable with accompanying immunization r(ePc)orsidti.ve or

Please check one box, and sign.

(N)egative

Equivocal is not

?MIMrReceived the Men_o_m_u_n/_e_/M__e/_n_a_c_tra/Menveo_/_M__e/n_i_n_g_o/c_o_c_c_al B (Trumenba)/

acceptable

Meningococcal B (Bexsero) /MCV4 at age 16 or older and within the past 5 years.

Measles

____/____/____

____/____/____

____/____/____

? I have read the attached information, and I will not receive the vaccine.

Mumps

____/____/____

____/____/____

Date: ______/______/______ _D__o_c/u_m__e_n/t_ed__M_ eningitis ______

____/_V_a_c_c/_in_e_D_ ate

______

SRigubnealtlua re_________________/_________/_________________________________________________

____/____/____

______

Date: ______/______/______

Menactra/

Students Signature or Parent/Guardian if under 18 years old

Menomune (not ____/____/____

PrAeqRuTire2d)- TO BE COMPLETED BY A HEALTHCARE PROVIDER OR ATTACH OFFICIAL IMMUNIZATION RECORD.

*PIrMovMideUr NNIaZmAeT__IO__N__H__I_S_T__O_R__Y__(_A_ll_d_a_te_s_m_u_st_i_n_cl_u_d_e _m_o_n_th_,_d_ay_, and*yLeaicr.ePnlesaes#e m__ar_k_a_n_(_X_)_in__th_e_appr*oSprtiaatteeboofxeLs.i)cense _________

MMR (measles, mumps, rubella) - if given as combined dose instead of individual vaccine.

DATE (mm/dd/year)

Dose 1: No more than 4 days prior to first birthday, AND on or after January 1, 1972

*Provider Phone (____)_____________ *Provider Signature ________________________________________________

Dose 2: At least 28 days after first vaccine

or

*ProvMideearsleSst(aRmubpeola) Dose 1 Immunized after 1968 and first birthday

Measles (Rubeola) Dose 2 Immunized at least 28 days after the first dose

*RMubEelNla INGITIISmmRuEnizSePd aOfteNr 1S9E69 a(nCdOonMor PaftLerEfirTstEbiDrthdBayY STUDENT OR PARENT/GUARDIAN IF STUDENT IS A MINOR.)

I

Mumps

have (or for

Immunized

students under

after

the

196O8 nanldyonaorr eafsteprofinrstsbeirtthodatyhe

age of 18, my child has):

survey below is

*Check One*

required

for

compliance.

or

C?hTIietechrka(bvOloeon(deotersft)osrhoswtuindgenpotssituivnedimermtuhneityag(deatoedf l1ab8,remsuyltscmhuilsdt bheaastt)achhaedd) the me ningoc occal m eningit is imm unization within the pasDt A1T0Ey(emamr/sdda/ynedar)the

specifMicedasaletseIgrGeceived is: ______/______/______ (You must enter month, day and year.) HadMutmhepsmIgeGningococcal meningitis immunization within the past 10 years. PARTICULAR DATE RECEIVED _____/_____/_____ ?I hRaIvheeaaR(dvumbe(eysldleaceeIhcgbiiGdladecdhkatosh)farttehaIids(ofthroerfombra)s,ctkourdoefhnatthsviesunfhodaredmr e,thxoepr lahagaienveeodfh1atod8,memxepy,latchihneielddin)tfwoorimlmleNa, tOthioTenionrbfeotgaraminraditiminogmn mureneginazriandtiginoogncomacgecanaiinlnsmgtoemcnoeicnncgianiltgidosicsdoeicascesaeal.semI.uenIndiunenrgsditteairsnsddtaitshneedasteh. e rriissHkkssEooAff nnLooTttrHreecCceeiAviviRningEgthPtheRevOvacaVccicIniDen.eE. RI hINavFeOdeRcMideAdTthIOatNI ((msigynactuhrielda)ndwsitlalmNpOreTquoirbedt)ain immunization against meningococcal meningitis disease.

HEALTHCARE PROVIDER STAMP

StNuadmeen_t_________________________________________________________________________/______/_T_e_lephoneO_R______P__a_r_e_n_t_/G__u_a_r_d__ia_n_____________________________________________________ ___/___/___

signature

date

(if student is a minor)

signature

date

Signature _________________________________________ License # _O__f_fi_c_e_U_s_e__O_n_l_y______________________________

SeAmdedsrteesrs_____________________________________________________________________________A_t_te_n_d_e_d__s_ch_o_o_l_i_n__U_.S__. _si_n_c_e_1_9_8_0______________

Credits _________________

Deferral Date ______/______/______

Appointments

Time

In-Progress Rel Waiver Temp-Medical Perm Med Waiver Military *required

______/______/______ ____________ ______/______/______ ____________

Letters Affidavit Signed

Warning ______/______/______ H.S. ____________

Non-complier ______/______/______ Year ____________

Please return this form to Student Health Services, Nassau Community College, Garden City, NY 11530-6793 RReevv. .0018/1/110

Phone (516)572-7123

Fax (516)572-9637

((oovveerr))

Please return this form to Student Health Office - 1 Education Drive Nassau Community College, Garden City, NY 11530-6793 Phone (516) 572-7123 Fax (516) 572-9637

Rev. 11/16

(over)

Back Page

Nassau Community College Student Health Office One Education Drive Garden City, NY 11530-6793

Phone (516) 572-7123 Fax (516) 572-9637 Healthoffice@ncc.edu

Immunization Information

Check with your local health department for vaccine availability. Student Health Office

Rev. 11/16

(over)

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