Thomas Brown Rudd Health Center - Hamilton College

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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 <strong>Health</strong> 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:
High Risk TB Regions Afghanistan Cook Islands Kenya Niger Syrian Arab Rep. Algeria Cóte d’Ivoire Kiribati Nigeria Tajikistan Angola Croatia Kuwait Pakistan Thailand Argentina Democratic People’s Kyrgyzstan Palau The former Yugoslav Rep. Armenia Republic of Korea Lao People’s Panama of Macedonia Azerbaijan Democratic Republic Democratic Papua New Guinea Timor-Leste Bahrain of the Congo Republic Paraguay Togo Bangladesh Djibouti Latvia Peru Tonga Belarus Dominican Republic Lesotho Philippines Trinidad and Tobago Belize Ecuador Liberia Poland Tunisia Benin El Salvador Libyan Arab Portugal Turkey Bhutan Equatorial Guinea Jamahiriya Qatar Turkmenistan Bolivia (Plurinational Eritrea Lithuania Republic of Korea Tuvalu State of) Estonia Madagascar Republic of Moldova Uganda Bosnia and Ethiopia Malawi Romania Ukraine Hezegovina French Polynesia Malaysia Russian Federation United Rep. of Tanzania Botswana Gabon Maldives Rwanda Uruguay Brazil Gambia Mali St. Vincent & the Uzbekistan Brunei Darussalam Georgia Marshall Islands Grenadines Vanuatu Bulgaria Ghana Mauritania Sao Tome & Principe Venezuela (Bolivarian Burkina Faso Guam Mauritius Senegal Republic of) Burundi Guatemala Micronesia Serbia Viet Nam Cambodia Guinea (Federated Seychelles Yeman Cameroon Guinea-Bissau States of) Sierra Leone Zambia Cape Verde Guyana Mongolia Singapore Zimbabwe Central African Haiti Montenegro Solomon Islands Republic Honduras Morocco Somalia Chad India Mozambique South Africa China Indonesia Myanmar Sri Lanka Colombia Iraq Namibia Sudan Comoros Japan Nepal Suriname Congo Kazakhstan Nicaragua Swaziland
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Thomas Brown Rudd Health Center - Hamilton College

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