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Health and Immunization Record Form

Welcome to the Stevens community. To assist in maintaining your health and the health of others on campus, the Student Health Center offers a caring, confidential environment. The State of New Jersey requires each student attending state-accredited institutions of higher education to provide his/her complete Immunization Record. Additionally, every full-time undergraduate and graduate student must also have a completed Health Record in the Student Health Center.

To comply with State of New Jersey legal requirements, and Stevens requirements, you must be immunized with two (2) doses of measles, one (1) dose of mumps, and one (1) dose of rubella vaccine prior to attending any classes. Additionally, recent legislation requires that all new students residing in Stevens housing receive one dose of meningitis vaccine (Menomune or Menactra vaccine are acceptable). College health centers in New Jersey must provide information about meningitis disease and keep records of the enrolling student's decision about whether or not to receive a meningitis vaccination if they are not residing in campus housing. Stevens Institute of Technology also requires students to have a PPD-Mantoux tuberculin skin test within six months of attending classes. Proof of the Hepatitis B series of vaccinations is also required of all new incoming full-time undergraduate and graduate students.

An incomplete Health and Immunization Record will result in a Registrar's hold being placed on your account. This means you will not be able to register in person or via the Web for any future classes until all forms are received by the Student Health Center. In extreme cases, when a student enrolls before a "hold" is placed against a student account, we also have the ability to disenroll you from classes if you do not provide us with state-required documentation in a timely manner. This is extremely serious as it can impact your visa status.

Please fill out this Health and Immunization Record so that you can satisfy New Jersey and Stevens requirements. Please note that the form(s) must be completed in full, signed, and dated by a healthcare provider/MD. If you have any questions concerning the above information, please contact the Student Health Center at (201) 216-5678.