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Immunization Record
The State of New Jersey enacted a law in 1995 requiring
each full-time student to provide the college with a valid record of immunization
verifying two (2) live doses of the MMR (Mumps, Measles and Rubella) vaccine
or verification of immunity and three (3) doses of Hepatitis B Vaccine.
If you plan to enroll full-time, submit either your high
school health record indicating two (2) lives doses or this form signed
by a physician to the Admissions Office prior to the first day of class.
- If you were born before 1957, you are exempt from this law.
- If you were born before 1968, you will probably need both live doses of MMR. Doses are administered one month apart.
- If you were born after 1968, you may have already received one live dose of MMR and will need an additional live dose.
- Students not immunized with the (3) doses of Hepatitis B Vaccine series would be permitted up to 9 months to be in compliance.
Print this form.
Bring or mail the completed form to:
Admissions Office
Mercer County Community College
P. O. Box B
Trenton, NJ 08690 USA
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| Last Name
|
First Name |
Middle Initial |
| Address |
| City
|
State |
Zip code |
| Social Security
No.
|
Phone Number |
Birth Date (Month/Day/Year) |
| First Enrolled at Mercer (Month/Year)
|
____ Male
____ Female |
Dates of Live Doses of Vaccines
| |
1st |
2nd |
3rd |
| MMR |
|
|
|
| Measles |
|
|
| Mumps |
|
|
| Rubella |
|
|
| Hepatitis B |
|
|
|
|
OR |
Blood Test
| |
Date |
| Measles Titer |
|
| Mumps Titer |
|
| Mumps Diagnosis |
|
| Rubella Titer |
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| Hepatitis B |
|
|
| Physician’s Signature
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Physician's # |
Date |
Exemption
____ I am exempt for medical reasons. Documentation from
my physician is attached.
____ I am exempt for religious reasons. Documentation
from my religious official is attached.
____ I am exempt because I was born before 1957.
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