Thomas Brown Rudd Health Center - Hamilton College

HAMILTON COLLEGE Immunization Record. To be completed and signed by a health care provider.
Name:______________________________________________________________________ Date of Birth:______/______/______
Last Name First Name MI
New York State Public Health Law §2165 requires all students born on or after Jan. 1, 1957 be adequately immunized against
Measles, Mumps and Rubella. You are legally required to provide this information and to get the necessary immunizations, or you
will be DENIED enrollment. If you qualify for a medical or religious exemption, please provide written documentation.
Enter info in MM/DD/YYYY format in English. You may attach copy of immunization record. Provider signature required at bottom of this page.
VACCINE GUIDELINES Dates Administered
MMR
2 doses required. 1st dose no
Dose #1: _____/_____/______
(Measles, Mumps, more than 4 days prior to 1st or document
Rubella combined) birthday and 2nd dose minimum Dose #2: _____/_____/______ of one of Positive Date of
OR: 28 days after dose 1 REQUIRED following: Titer Disease
Measles 2 doses required as above if no MMR 1.____/____/_____ 2.____/____/_____ ######## ___/___/____ ___/___/____
Mumps 2 doses required as above if no MMR 1.____/____/_____ 2.____/____/_____ ######## ___/___/____ ___/___/____
Rubella 2 doses required as above if no MMR 1.____/____/_____ 2.____/____/_____ ######## ___/___/____ N/A
Tetanus - Dip. Primary series with booster in 1.____/____/_____ 2.____/____/_____ 3.____/____/_____ 4.____/____/_____
last 10 years 5.____/____/_____ Booster: ☐ Td or ☐ Tdap ___/____/_____
Polio Primary series 1.___/___/____ 2.___/___/____ 3.___/___/____ 4.___/___/____
Varicella Two doses recommended if no 1.___/___/____ or documentation of Positive titer: ___/___/_____
documented history of disease 2.___/___/____ or history of disease date: ___/___/_____
Hep B Recommended 3 dose series 1.___/___/____ 2.___/___/____ 3.___/___/____
HBSAA: ___/___/____ ☐ R or ☐ N-R
Meningitis Recommended. If not received, 1.____/____/_____ 2.____/____/_____ ☐Menomune ☐Menactra ☐Menveo
patient signature required on waiver I have been informed about the risks of Meningitis and decline the immunization at this time:
to the right:
Pt. Signature:______________________________________________ Date____/____/_____
Hep A Recommended two dose series 1.____/____/_____ 2.____/____/_____
HPV Recommended 3 dose series 1.____/____/_____ 2.____/____/_____ 3.____/____/_____
Mantoux Required if Student is High Risk Placed:____/____/_____ Read:____/____/_____ Result:_____mm induration
HX of previous
BCG vaccine
does not preclude
Send copy of chest x-ray report:
If > 10 mm induration, or positive IGRA, chest x-ray required
Date: ____/_____/_____ Result:_________________________
Mantoux testing if
Send copy of lab report:
IGRA Date:____/____/_____ Please specify: ☐ QFT-G ☐ QFT-GIT ☐ T-SPOT
indicated high risk.
Result: ☐ NEG ☐ POS ☐ INDETE. ☐ BORDERLINE (T-Spot ONLY)
Provider Name (please print)
Provider Signature
Date
Phone:
Fax:
Address
or Office Stamp: