View and Complete the Immunization Form
According to Massachusetts law 105 CMR 220.600, all full-time students (12 or more
credits) under the age of 30 and all full-time and part-time students in Health Profession
programs must present evidence of immunization against measles, mumps, rubella; tetanus,
diphtheria and pertussis; varicella (chickenpox), Hepatitis B, and Meningitis (if
21 years and under), to attend classes. Immunization verification must be signed and dated by the health care provider to be considered complete.
- PART A of this form must be completed by all students enrolling in the college. It must be signed and dated by the student.
- PART B of this form must be completed by the health care provider, if required by the categories
outlined in the form and listed above.
- PART C of this form must be completed by all students. (Please print clearly in that section.)
This form must be completed within 30 days of the start of the semester. Once completed,
this form should be sent to:
Wellness Center
Kara Lopez, RN-MSN, PMHNP-BC
Health Science Building (4), Room 313
Email: studentimmunization@rcc.mass.edu
Fax: 833-392-7712
For accommodation requests or to connect with Accessibility Services (SAS), please
contact:
Student Accessibility Services (SAS)
Academic Building (3), Room 201
Email: studentimmunization@rcc.mass.edu
Tel: 857-701-1278
If you have any questions about the Immunization and Health Information Form or process, please direct all inquiries to:
Wellness Center
Kara Lopez, RN-MSN, PMHNP-BC
Health Science Building (4), Room 313
Email: studentimmunization@rcc.mass.edu
Fax: 833-392-7712