STATE I MMUNIZATION P O LI CY
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If you were born after December 31, 1956, Connecticut State Law requires that all full-time (degree seeking and non-degree/non-matriculating)
and part-time matriculating students enrolled in postsecondary schools be adequately protected against measles, mumps and rubella. In addition,
beginning on August 1, 2010 all full-time and matriculating students, except those born in the continental United States prior to January 1, 1980,
must provide proof of immunization against varicella (chicken pox). Students must have two (2) doses of each vaccine administered at least one
(1) month apart to insure adequate immunization
if you are not exempt, please complete one of the options below and attach the necessary documentation.
SUSAN DESROSIERS
Name of Student Date of Birth
02 05
/ /
1970
Address
10 ARBOR DR NORWALK CT 06854
Street City/Town State Zip Code
OPTION 1: RECORD OF IMMUNIZATION OPTION 2: LAB EVIDENCE OF IMMUNITY
This section must be completed by either a physician or someone OR CONFIRMED CASE OF DISEASE
operating under the direction of a physician (ex. School nurse, Test results (Titer) for lab evidence must be attached to this form
physician’s assistant, or nurse practitioner). or document that you have already had the disease(s). If you cannot
document a confirmed case of the disease(s), then you must submit
immunity results from a medical laboratory.
Vaccination 1st 2nd Date of Test Result of Date of
Type Dose Dose Test Disease
Measles mo/day/yr mo/day/yr mo/day/yr
/ / / / / /
Mumps mo/day/yr mo/day/yr mo/day/yr
/ / / / / /
Rubella mo/day/yr mo/day/yr mo/day/yr
/ / / / / /
OR
MMR mo/day/yr mo/day/yr mo/day/yr
/ / / / / /
AND
Varicella mo/day/yr mo/day/yr mo/day/yr
(Born after 1/1/1980) / / / / / /
OPTION 1 & 2: This must be completed by your physician. I hereby certify that this student has
received the immunization(s) or has laboratory evidence of immunity as indicated.
Signature of physician or authorized person Date
Physician’s stamp or
DEA number
OPTION 3: Medical exemption on the reverse side
I M M U N I Z A T I O N WA I V E R S
OPTION 3: MEDICAL EXEMPTION
Students with medical exemptions shall be permitted to attend college except when, in accordance with Connecticut General Statute section 10a-
155a, a public health official has reason to believe that the presence of the non-immunized person presents a clear danger to others. Students
excluded from college for this reason will not be able to return to school until the student presents to college a certificate from a physician,
physician assistant or advanced practice registered nurse that the student’s presence does not present a clear danger to the health of others.
According to State statutes, (Connecticut General Statutes Section 10a-155) no student may enroll in an institution of higher education without
proof of immunization or a statement of exemption. Students seeking an exemption on the basis that a given immunization is medically
contraindicated must attach a statement to the form signed by their physician stating that in the physician’s opinion, such immunization is
medically contraindicated and why it is contraindicated. In addition, the student should complete the following statement and return it to the
Admissions Office.
I am submitting the enclosed documentation from a physician that immunization is medically contraindicated. Therefore, I am exempt from
receiving the required immunization as specified by the physician, and shall be permitted to attend college except in the case of a vaccine-
preventable disease outbreak in the school.
SUSAN DESOIRES
Student Name Student Signature
NOTE:
Pursuant to Connecticut General Statute 10a-155, religious exemptions will be granted only to those students who provided statements requesting
the exemption prior to April 28, 2021. No religious exemptions will be granted after April 28, 2021.
