REQUIRED Auraria Campus Immunization Compliance Form
Approved Alternate Certificate of Immunization - Colorado Department of Public Health and Environment – July 2014
First Name
Requirement: Students must submit proof of measles/mumps/rubella (MMR) vaccinations or evidence of immunity and complete steps 1-3 on page one of this form according to the following requirements.
Students born after January 1, 1957 must complete steps 1-3 below by providing documented proof that they have received two measles, two mumps and two rubella (German measles) vaccinations OR two combination MMR vaccinations. Exemptions are allowed by 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, complete step 1, skip step 2 and submit as outlined in step 3.
M.I. Last Name
Student ID # Date of Birth Social Security #
Street Address City State Zip
Primary Phone
Secondary Phone (if available)
School: UCD MSU Denver Status: Student Faculty Staff
CCD AHEC
If you attach a copy of your immunization record to this form you can skip this section and proceed to STEP 3. If your immunization record is unavailable, you must have your physician complete the Certificate of Immunization below.
REQUIRED VACCINE DATE GIVEN REQUIRED VACCINE DATE GIVEN
Combined MMR - Shot 1
OR
Separate Measles - Shot 1
DATE GIVEN
MMR Combined #2
OR
Separate Measles - Shot 2
DATE GIVEN
Separate Mumps - Shot 1 Separate Mumps - Shot 2
Separate Rubella - Shot 1
Meningococcal
Signed
(physician, nurse or school health authority)
Title Date
Option 1: Mail this form and MMR records to Auraria Immunizations, PO Box 173362, Campus Box 15, Denver, CO 80217-3362.
Option 2: Hand deliver form to Auraria Immunization Office, Plaza 149 (adjacent to the Student Health Center at Auraria.)
An after-hours drop box is located outside of the Immunization office, Plaza 149. Place all drop box items in a sealed envelope.
Option 3: Fax to 303-556-5341 and include your full name, student ID number and phone number on a separate cover page.
*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 addition, it is important for students to be aware that if they opt to exempt themselves by not providing proof of MMR documentation there are implications associated with this choice. In the event of a disease 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.
MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically contraindicated.
Physician Signature: ____________________________________________________________Date____________________ Exempted To_________________________
RELIGIOUS EXEMPTION: Person himself/herself is an adherent to a religious belief opposed to immunizations.
Signed parent, guardian or student 18 years and older___________________________________________________________________ Date______________________
PERSONAL EXEMPTION: The named person or the person himself/herself is an adherent to a personal belief opposed to immunizations.
Signed parent, guardian or student 18 years and older___________________________________________________________________ Date______________________
Auraria Campus Immunization Form Page 1 of 2

 Meningococcal disease is a serious disease, but is largely preventable.

Meningococcal disease is a contagious bacterial 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 U. S.: 10-15 % of these people die, in spite of treatment with antibiotics. Of those who live, another 10 % 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 student housing are at increased
risk of contracting meningococcal disease.

Receiving the vaccination 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.

To receive the meningococcal vaccination against meningococcal disease, students should check with their college health center, health care provider or local health department.

For a list of public health departments/agencies in Colorado, go to https://www.colorado.gov/pacific/cdphe/find-your-local-public-health-agency

For more immunization information www.cdc.gov/vaccines/pubs/vis/default.htm
Students: 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?
Auraria Campus Immunization Form Page 2 of 2