REQUIRED Auraria Campus Immunization Compliance Form

Certificate of Immunization - Colorado Department of Public Health and Environment – January 2018

Auraria Campus Immunization Requirements & State of Colorado Law

Requirement: Students must submit proof of measles/mumps/rubella (MMR) vaccinations or evidence of immunity. Exemptions are permitted by State law, but have implications for class attendance and tuition/fees.
 
*Students born before January 1, 1957 are assumed to have been exposed to disease and are EXEMPT from the MMR requirement. In this case, only complete step 1,read the Public Health Alert section and click SUBMIT at the bottom of the page.

Complete Steps 1 and 2 and read the Public Health Alert to avoid having a HOLD placed on your student account

Step 1: Complete all of the personal data below

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School: *

Step 2: Select a proof of immunization option (choose only one)

Option 1: Attach a copy of your immunization records designating two doses of measles, mumps and rubella vaccine, OR 2 MMR vaccinations, OR

Option 2: Attach a copy of your blood titer test results



OR

 
Option 3: Have your healthcare provider complete the information below
REQUIRED VACCINE -------------------------------------------------------------------------- DATE(S) GIVEN
 12
Two Combination MMR's (Measles, Mumps, Rubells)
OR
 12
Two Measles
Two Mumps
Two Rubella
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STATEMENT OF EXEMPTION TO THE IMMUNIZATION LAW

A primary goal of the State Immunization law is to prevent the spread of disease and to lessen the health risks associated with communicable disease(s). Colorado law regarding immunizations requires that students provide their immunization records or get immunized in order to best protect all Auraria constituents. IN THE EVENT OF AN OUTBREAK, exempted individuals may be subject to exclusion from the Auraria campus and to potential quarantine. Additionally, applicable institutional policies related to forfeiture of tuition and fees may apply.
 

To request a non-medical or a medical exemption complete option A or option B below.

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Option A: NON-MEDICAL EXEMPTION (religious or personal belief opposed to immunizations):
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Option B: MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated.
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PUBLIC HEALTH ALERT: For your personal health & safety read the information on this page placed on your student account

MENINGOCOCCAL DISEASE INFORMATION

Meningococcal disease is a serious disease, caused by a bacteria.

Meningococcal disease is a contagious, but a largely preventable, infection of the spinal cord fluid and the fluid that surrounds the brain. Meningococcal disease can also cause blood infections.

About 2,600 people get meningococcal disease each year in the United States; 10 to 15 percent of these people die, in spite of treatment with antibiotics. Of those who live, another 10 percent lose their arms or legs, become deaf, have problems with their nervous system, become mentally retarded, or suffer seizures or strokes.

Anyone can get meningococcal disease, but it is most common in infants less than one year of age and in people with certain medical conditions.

Scientific evidence suggests that college students living in residence hall facilities are at a modestly increased risk of contracting meningococcal disease.

Immunization against meningococcal disease decreases the risk of contracting the disease. Meningococcal vaccine can prevent four types of meningococcal disease; these include two of the three most common in the United States. Meningococcal vaccine cannot prevent all types of the disease, but it does help to protect many people who might become sick if they do not get the vaccine.

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions.The risk of the meningococcal vaccine causing serious harm, or death, is extremely small. Getting a meningococcal vaccine is much safer than getting the disease.

More information can be obtained from the Vaccine Information Statement available at: https://www.cdc.gov/vaccines/hcp/vis/index.html. Students and their parents should discuss the risks and benefits of vaccination with their health care providers.

TUBERCULOSIS (TB) RISK ASSESSMENT

Please answer the following questions. If you answer “YES” to any of the questions and/or have any of the symptoms listed in question #7, you should consult with a medical provider as soon as possible since you may be at greater risk for contracting TB or in need of additional medical evaluation(s).

  1. Are you from or have you lived for two months or more in Asia, Africa, Central or South America or Eastern Europe?
  2. Have you been diagnosed with a chronic condition that may impair your immune system?
  3. Have you resided/worked/volunteered in a prison/hospital/nursing home/homeless shelter/long term treatment center?
  4. Have you ever had contact with a person known to have active tuberculosis?
  5. Have you ever used injection drugs?
  6. Have you ever had a positive (reactive) tuberculin skin test for tuberculosis?
  7. Do you currently have any of the following symptoms…? cough of greater than 3 weeks * night sweats
    • shortness of breath * loss of appetite * a productive cough * weight loss *unexplained fatigue * weakness
    • unexplained fever * chest pain * chills * or are you coughing up blood?