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Medical Record Form

MA law 105 CMR220.700 requires all new and transfer students at post secondary institutions that provide housing to provide documentation of having received the meningococcal vaccine within the past 5 years or at least 2 weeks prior to the beginning of classes. No student shall begin classes without this certificate unless the student qualifies for one of the exemptions allowed by the law:

(1) the student provides written documentation that he or she meets the standards for medical or religious exemption set forth in M.G.L. c. 76, ss 15C;

(2) the student, or the student’s parents or guardian if the student is a minor, signs the enclosed waiver stating that the student has received information about the risks and dangers of meningococcal disease, has reviewed the information provided and has elected to decline the vaccine (waiver exemption). A signed copy of this information and waiver form must be kept on file in Health Services.

Each student must also present a certificate of immunization that the student has also received the following immunizations (105 CMR 220.600):

  • at least one dose of mumps and rubella vaccine(s) given at or after 12 months of age;
  • two doses of live measles vaccine given at least one month apart beginning at or after 12 months of age;
  • a booster dose of Td within the last ten years;
  • 3 doses of hepatitis B vaccine

Exemptions to Ma law 105 CMR 220.600:

(1) the student provides written documentation that he or she meets the standards for medical or religious exemption set forth in M.G.L. c. 76, ss 15C;

(2) in the case of measles, mumps, rubella and hepatitis B, the student presents laboratory evidence of immunity.

As of April 19, 2006 in a joint statement from the American College Health Association and Centers for Disease Control and Prevention (CDC) the following recommendations are made for mumps prevention:

Because undergraduate and graduate students, faculty, and health care and other workers in colleges and other post-high school educational institutions may be at increased risk of acquiring mumps, they should receive two doses of MMR vaccine or provide other evidence of mumps immunity (physician diagnosis or laboratory evidence).

If you are presently receiving allergy injections and wish to continue allergy immunotherapy at Holy Cross please contact Health Services at 508-793-2276, Mon. - Fri. between 8:30 a.m. and 5:30 p.m.

Medical Record Forms have been mailed out. If you did not receive one, or if you need an additional copy, you may download one below. Forms must be returned by August 18, 2008.

If you are a varsity athlete, you must also complete the pre-season medical history section of the medical record form (Part C). The Sports Medicine Dept. requests that the forms be returned to Health Services by July 15, 2008.