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 maintenance of a student health record is essential for all students. Please read below to understand the requirements for students living on and off campus.
The State of New Jersey requires each student attending state-accredited institutions of higher education to provide his or her complete Immunization Record. Additionally, every full-time undergraduate and graduate student must also have a completed Student Health and Immunization Record in the Student Health Center.
To comply with State of New Jersey legal requirements and Stevens requirements, full-time students must be immunized with:
- Two (2) doses of measles vaccine
- Two (2) doses of mumps vaccine
- Two (2) doses of rubella vaccine
- One (1) dose of meningitis vaccine (required by NJ law for NEW students living in Stevens OWNED OR LEASED housing). Meningococcal vaccine covering serogroups A, C, Y, and W-135. We accept Menactra, Menomune, or Menveo. If the initial dose was administered before the 16th birthday, a booster dose should be administered after the 16th birthday. The minimum interval between doses of meningococcal conjugate vaccine is 8 weeks. (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 OWNED OR LEASED housing).
- Proof of the Hepatitis B series of vaccinations (Three (3) doses)
- PPD/Mantoux tuberculin skin test within six months of attending classes and a chest x-ray written report if positive (10mm or greater)
- Two (2) doses of Varicella vaccine or documented proof of having had Chicken Pox Disease
An incomplete Student Health and Immunization Record will result in a Registrar's hold being placed on your student 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 or your choice of classes.
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 English, signed, dated, and stamped by a healthcare provider/MD. Copies of all immunization documents must be officially translated into English before they are presented as well. If you have any questions concerning the above information, please contact the Student Health Center at (201) 216-5678.
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