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Health Services
Rutgers, The State University of New Jersey
11 Bishop Place
New Brunswick, NJ 08901-1180
APPENDIX A
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Immunization Record
PARTI:Tobecompletedbythestudent
Lastname
Firstname
MI
RUID#
DateofBirth
StreetAddress
Telephone(cell)
City
State
Zip
DOSE #1
DATE
DOSE #2
DATE
DOSE #3
DATE
DATE OF
POSITIVE
IMMUNE TITER
OR
MEASLES
2 Doses REQUIRED
MUMPS
2 Doses REQUIRED
RUBELLA (German Measles)
2 Doses REQUIRED
2.
*MENINGOCOCCAL M ENINGITIS
REQUIRED for all undergraduate, graduate and transfer students
who are living in University housing. At least one (1) dose
required since age 16.
3. HEPATITIS B
REQUIRED 3 doses or immunity titer for students taking 12 or more
credits per semester.
TB TESTING
Rutgers University requires Tuberculosis Testing (Mantoux PPD or FDA approved blood test) within 6 months prior to attending the University
and chest x-ray report (if indicated for positive results) for incoming students who hold non-immigrant visas and were born or grew up in a
country* with a high prevalence of tuberculosis. Testing is required regardless of prior BCG vaccination.
It is easier to list the countries that DO NOT have a high incidence of TB and therefore, individuals from the following countries DO NOT require
screening tuberculin testing: Canada, Jamaica, Saint Kitts and Nevis, Saint Lucia, Virgin Islands, Belgium, Denmark, Finland, France,
Germany, Greece, Iceland, Ireland, Italy, Liechtenstein, Luxembourg, Malta, Monaco, Netherlands, Norway, San Marino, Sweden, Switzerland,
United Kingdom, American Samoa, Australia, Austria or New Zealand. All others not listed in the above list are required to submit PPD status.
4. TUBERCULOSIS TESTING
A.
OR
B.
C.
'DWH
Positive
Negative
_______mm
Result
X-ray
Date
Normal
Abnormal
Treatment
Date
Health Services
Rutgers, The State University of New Jersey
11 Bishop Place
New Brunswick, NJ 08901-1180
P: (848) 932-7402
F: (732) 932-8255
Hepatitis A
Gardasil 9
Gardasil
HPV Vaccine
Polio
TD
Tdap (Adult) One-time administration
Varicella (Chickenpox)
DOSE #1
DATE
DOSE #2
DATE
DOSE #3
DATE
DATE OF
POSITIVE
IMMUNE TITER
Cervarix
* Meningococcal Meningitis, the second most common cause of Bacterial Meningitis in the United States, is a rare, but
potentially fatal disease with early symptoms that resemble the flu, making diagnosis difficult. It causes inflammation of the
membranes surrounding the brain, spinal cord and can also infect the blood stream. Progressive symptoms include high
fever, severe headache, stiff neck, confusion, nausea, vomiting, exhaustion and/or rash. If not treated early, meningitis can
lead to severe disabilities and death. Despite appropriate antibiotic treatment, nearly 10% will die. The disease strikes about
3,000 Americans yearly and claims 300 lives. It is estimated that between 100 and 125 Meningitis cases occur on college
campuses alone, and that as many as 16 students will die from the disease annually. Meningococcal bacteria are
transmitted by air droplets (coughing or sneezing) and by direct contact with an infected person (sharing a glass, cigarette or
kissing). Meningococcal infection is not contracted by casual contact, such as being in a classroom. It occurs throughout the
year, but usually peaks in late winter and early spring.
On February 26, 2015, the US Center for Disease Control & Prevention (CDC) Advisory Committee on Immunization
Practices (ACIP) voted to recommend serogroup B meningococcal vaccination for ONLY persons aged 10 years or older at
increased risk for meningococcal disease, including:
As a result of state immunization law, Rutgers University requires new, first year undergraduates, graduates and transfer
students who live in campus housing receive the standard Meningococcal vaccine. Research shows that first year students
living in residence halls may have up to a six fold increased risk for the disease as compared with college students overall.
Since the disease can affect people of any age, other college students may wish to consider the vaccination.
More information about meningococcal disease can be found at:
http://www.nj.gov/health/cd/meningo/index.shtml
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mening.html
I have received information about the nature of meningococcal meningitis disease, disease prevention and treatment,
and the availability of meningococcal vaccine to prevent disease. Further, I understand in the event of an outbreak,
the Commissioner of Health or designee may issue additional immunization requirements to meet the public health
emergency. In the event of this type of contagious outbreak, any student who has been exempted from or failed to
comply with the pertinent immunization may not be allowed on campus until the outbreak is over.
______________________________________________ _________________
Students Signature
Date
REQUIRED
HEALTH CARE PROVIDER Name, Address
AND SIGNATURE (REQUIRED)
vaccine@rci.rutgers.edu
By Mail:
RUTGERS UNIVERSITY
ATTENTION: IMMUNIZATIONS
57 US HIGHWAY 1
NEW BRUNSWICK, NJ 08901
Health Services
Rutgers, The State University of New Jersey
11 Bishop Place
New Brunswick, NJ 08901-1180
P: (848) 932-7402
F: (732) 932-8255
APPENDIX B:
Instructions for accessing the New Jersey Immunization Requirements
o http://www.nj.gov/health/cd/documents/instructions_viewing_regulations.pdf
Q: What is considered grounds for filing a medical exemption?
A: A medical exemption must indicate a specific period of time in which the child cannot
receive specific vaccinations. Reason(s) for medical contraindication must be enumerated by
the ACIP and the American Academy of Pediatrics (AAP). Precautions to receiving a vaccine
are not contraindications but a provider must take into consideration
http://www.immunize.org/catg.d/p3072a.pdf
Q: Do medical exemptions have to be renewed annually?
A: Medical exemptions need to be reviewed, but not necessarily updated, annually. Per
NJAC 8:57-4.3 (c), when a child's medical condition permits immunization, this exemption
terminates and the child will be required to obtain the immunization(s) from which he/she has
been exempted. A medical exemption must indicate a specific period of time in which the
child cannot receive specific vaccinations.
For example if a child was granted a medical exemption because he/she was on medication
that was contraindicated for one or more vaccines, that child would not be required to receive
those specific vaccinations until the specified time period has elapsed. If the child is still
medically contraindicated and the time period has elapsed, a new medical exemption would
need to be submitted.
Q: What should be included in an acceptable religious exemption?
A: A religious exemption is not the same as a philosophical, moral or conscientious
exemption. A religious exemption does not have to include the name of the religion, nor does
it need to be notarized nor does it need to be signed by a religious leader. It can be filed by a
parent or guardian of a minor or by an adult individual.
All schools, child care centers, and local health officers may be advised that the religious
exemption extends to private, parochial, and public institutions. When a parent or guardian
submits their written religious exemption to immunization, which contains some religious
reference, those persons charged with implementing administrative rules at N.J.A.C. 8:57
4.4, should not question whether the parents professed religious statement or stated belief is
reasonable, acceptable, sincere and bona fide. In practice, if the written statement contains
the word religion or religious or some reference thereto, then the statement should be
accepted and the religious exemption of mandatory immunization(s) granted. Please note,
religious-affiliated schools cannot be challenged on their decision.
Q: Do religious exemptions have to be renewed annually?
A: Religious exemptions do not need to be updated yearly. However, if children receive
vaccines after a religious exemption has been granted, the exemption would become null
and void.
The following example may provide some clarification: In the beginning of the school year, a
child was granted a religious exemption so he/she did not have to receive any of the required
vaccines. Later on in the school year, the child provides documentation of receiving one
dose of Tdap (or another required vaccine). Since the child now has received a vaccine from
which he was previously exempted, the religious exemption is now null and void. This means
he would now be responsible for receiving all of the required vaccines from which he was
previously exempted.
Health Services
Rutgers, The State University of New Jersey
11 Bishop Place
New Brunswick, NJ 08901-1180
P: (848) 932-7402
F: (732) 932-8255
APPENDIX C
RELIGIOUS GROUNDS
Receipt of vaccination and immunization would conflict with his/her sincere religious beliefs.
(To be explained by student)
Please explain
Please explain
Health Services
Rutgers, The State University of New Jersey
11 Bishop Place
New Brunswick, NJ 08901-1180
P: (848) 932-7402
F: (732) 932-8255
APPENDIX D
REQUIRED
TB Testing
Please include date placed and date read with millimeters of induration
For a PPD 10 mm now or in the past, you must submit a chest x-ray report and
treatment date, if applicable.
OR
FDA approved blood test for TB (such as Quantiferon Gold) - attach lab report
*Please do testing (either PPD or Blood Test for TB) regardless of history of having received BCG
(1st dose given after the first birthday and 2nd dose least one month after the 1st dose)
MMR
OR
Meningitis
OR
OR