Clinton Community College
Nicole A. (Powers) Allen RN
Student Support Services Nurse
The Health Office is located in Room 149 of the main building. Services available Monday - Friday 8:00 a.m. - 4:00 p.m.
Services Provided:
- First Aid and emergency services
- Health Promotion and Maintenance
- Referral to Local Agencies and Physicians
- Blood Pressure Screening
- Rest Area
- Accident Insurance for Full-time Students - Accidents must be reported immediately to the College Nurse-insurance covers accidents both on and off campus (acute or chronic medical conditions or illnesses are not covered)
- Information on a variety of health related topics:
- Stress Management
- Diet and Weight Control
- Contraceptive Choices
- Sexually Transmitted Infections
- Injury Prevention
- New - Total Wellness Club/Kick Boxing
- and much, much more...
- Full-time and part-time students born on or after January 1, 1957 must show proof of immunity against measles, mumps, and rubella. Failure to comply with the New York State Dept. of Health Law will result in administrative withdrawal from school with no refund of tuition or fees.
- All students must complete Meningococcal Meningitis information on "Immunization Record" (see below) and return form to the Health Office prior to registering for classes. Note: Meningitis immunization IS NOT REQUIRED.
Immunization Record
Submit this form to the Health Office PRIOR TO registering for classes.
Name ________________________________________ Social Security # (optional) _______________________
Address ________________________________________ Date of Birth __________________________________
________________________________________
New York State Public Health law 2165 now requires post-secondary students to show immunity against Measles (Rubeola), Mumps, and Rubella (German Measles). Persons born prior to January 1, 1957 are exempt from this requirement unless the individual is in a degree program that requires this documentation (i.e. Nursing, MLT). Students taking on-line courses only are also exempt. Meningococcal Meningitis information (below) must also be completed.
REQUIRED: Measles (Rubeola) Immunity—Must have ONE of the following three:
1. TWO dates of *Measles Immunization: (1)____________________ and (2)____________________
Both must be given after 1967 and the first shot must be on/after 12 months of age, the second shot must be on/after 15 months of age. (*MMR vaccine recommended for both).
2. Date of Measles Titer:____________________. Results:_________________________
3. Date of Physician’s diagnosis of disease (record must include Physician’s signature) ____________________
REQUIRED: Mumps Immunity—Must have ONE of the following three:
1. Date of one Mumps Immunization: (1)____________________. Must be on/after 12 months of age.
2. Date of Mumps Titer:____________________. Results:_________________________
3. Date of Physician’s diagnosis of disease (record must include Physician’s signature) ____________________
REQUIRED: Rubella Immunity—Must have ONE of the following two:
1. Date of one Rubella Immunization: (1)____________________. Must be on/after 12 months of age.
2. Date of Rubella Titer:____________________. Results:_________________________
*Physician diagnosis is NOT acceptable for Rubella Immunity.
Doctor’s Name & Practice Name (PRINT):________________________________________
Doctor’s Signature:____________________________________________ Date:_________________________
Meningococcal Meningitis (check one box and sign below, parents must sign if student’s age is under 18).
o I have had the meningococcal meningitis (Menomune or Menactra) immunization within the past 10 years.
Date vaccine administered:____________________.
o I have read, or have had explained to me the information regarding meningococcal meningitis disease and will obtain immunization against meningococcal meningitis within 30 days from my health care provider or the Health Department.
o I have read, or have had explained to me the information regarding meningococcal meningitis disease and understand the risks of not receiving the vaccine. I have decided that I will NOT obtain immunization against meningitis.
Student/Parent Signature:________________________________________ Date:_________________________
RECOMMENDED VACCINES
Date of Tetanus (Td) booster:____________________ (should be every 10 years).