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Immunizationrequirements 2

New York State law and Farmingdale State College require students born after January 1, 1957 to provide proof of immunizations for measles, mumps, and rubella. Nursing, dental hygiene, and medical laboratory technology students must also submit titers for Hepatitis B, Measles, Mumps, Rubella, Varicella, Meningococcal, and TDAP. The form must be signed by a provider and returned to the Health and Wellness Center at Farmingdale State College.

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25 views1 page

Immunizationrequirements 2

New York State law and Farmingdale State College require students born after January 1, 1957 to provide proof of immunizations for measles, mumps, and rubella. Nursing, dental hygiene, and medical laboratory technology students must also submit titers for Hepatitis B, Measles, Mumps, Rubella, Varicella, Meningococcal, and TDAP. The form must be signed by a provider and returned to the Health and Wellness Center at Farmingdale State College.

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yivoc16035
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LAST NAME, FIRST______________________________________DATE OF BIRTH____________________ RAM ID_____________________________

IMMUNIZATION REQUIREMENTS

New York State law and Farmingdale State College, in keeping with recommendations of the American College Health
Association and the Centers for Disease Control, require all students born on or after January 1, 1957 who are attending
an institution of higher education to show proof of two doses of live measles vaccine, one dose of live mumps vaccine
and one dose of live rubella vaccine, given after one year of age. In lieu of immunization dates, the physician may provide
a date of disease for measles and mumps only; history of rubella disease is not acceptable. Student may also choose
to have blood tests called titers in lieu of immunizations which will show actual levels of immunity to each of the three
diseases. If titers are drawn, please attach copies of actual laboratory reports.

ALL NURSING, DENTAL HYGIENE AND MEDICAL LABORATORY TECHNOLOGY STUDENTS


MUST SUBMIT THE FOLLOWING TITERS, WHICH ARE REQUIRED FOR THEIR CLINICAL ROTATIONS:
Hepatitis B (or proof of shots) Measles Mumps
Rubella Varicella
Please use grid below to enter information. Please attach copies of laboratory reports for all titers.

IMMUNIZATION REQUIREMENTS
If blood titers were drawn, please attach lab report

IMMUNIZATION DATE DATE DATE IMMUNIZATION DATE DATE DATE

MMR HEPATITIS B

MEASLES MENINGOCOCCAL
within 5 years for resident
students required
MUMPS
TDAP
within 10 years
RUBELLA

Provider’s Signature Required ���������������������������������������������������


OFFICE STAMP REQUIRED
Print Name______________________________________________________________________

Address_________________________________________________________________________

Phone (______)___________________________ Fax (______)____________________________

RETURN THIS FORM TO:


Health and Wellness Center
Farmingdale State College
2350 Broadhollow Road
Farmingdale, NY 11735

Health + Wellness Center ( 934-420-2009 934-420-2137 + [email protected]

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