IMMUNIZATION RECORDS DEADLINE: FIRST OFFICIAL DAY OF CLASSES OFFICE OF INSURANCE AND IMMUNIZATION RECORDS 525 West 120th Street, Box 308 New York, New York 10027
[email protected] | (f): (212) 678-3681
PLEASE RETAIN A COPY FOR YOUR RECORDS. NAME _________________________________________________ (Pl ease Pri nt) Last / Family
_______________________________________________ Fi rs t / Given
TC ID #: T ________________________________________
DATE OF BIRTH _______ / _______ / ________
PART I: PROOF OF IMMUNITY TO MEASLES, MUMPS, AND RUBELLA REQUIRED FOR ALL STUDENTS BORN ON OR AFTER JANUARY 1, 1957. ALL PORTIONS OF SECTION A OR SECTION B BELOW MUST BE COMPLETED BY A PHYSICIAN OR A HEALTH CARE PROVIDER. Section A—MMR (Measles, Mumps, and Rubella) st
1 Dose: Immunized on or after first birthday AND nd st 2 Dose: Immunized after 15 months of age or at least 28 days after 1 dose Section B—Part 1: MEASLES 1._______History of illness documented by Health Care Provider
Month / Day / Year ______ / ______ / ________ ______ / ______ / ________ Month / Day / Year ______ / ______ / ________
Or 2._______ Immunity Proven by Immune Titer—MUST SUBMIT COPY OF LAB REPORT ______ / ______ / ________ Or st
______ / ______ / ________
st
______ / ______ / ________
3._______1 Live Virus Dose: Immunized on or after first birthday AND nd 2 Live Virus Dose: Immunized after 15 months of age or at least 28 days a fter 1 dose Section B—Part 2: MUMPS 1._______Hi s tory of illness documented by Health Ca re Provi der Or 2._______ Immunity Proven by Immune Titer—MUST SUBMIT COPY OF LAB REPORT
______ / ______ / ________
______ / ______ / ________ Or 3._______1st Li ve Vi rus Dose: Immunized on or a fter first birthday
______ / ______ / ________
Section B—Part 3: RUBELLA 1._______ Immunity Proven by Immune Titer—MUST SUBMIT COPY OF LAB REPORT
______ / ______ / ________ Or st
2._______1 Li ve Vi rus Dose: Immunized on or a fter first birthday
______ / ______ / ________
NOT VALID UNLESS SIGNED AND STAMPED BY HEALTH CARE PROVIDER PROVIDER STAMP
Provider Name ___________________________________________________________ Provider Signature ________________________________________________________ Provider Address _________________________________________________________
RECORDS CAN BE SUBMITTED VIA MAIL, myTC PORTAL, AND FAX. PLEASE NOTE: WE DO NOT ACCEPT RECORDS VIA EMAIL.
