Immunization records & health history form
Complete your forms and submit to Health Services via:
- Email: HealthCenter@mail.sunyjcc.edu
- Fax: 716.338.1461 or 716.376.7021
- In person at your campus health center
You will be in administrative withdrawal from JCC and charged a $25 fine if you don’t turn in your forms and records.
COVID-19 vaccination form
SUNY will require every student interacting or taking classes on any SUNY campus to be fully vaccinated for COVID-19, pending FDA approval of at least one vaccine.
While approval is pending, students should start the vaccination process immediately if coming to campus for any classes or campus activities. Upon receiving your vaccination, please submit the form:
If a student is taking online coursework only and has no plans to participate in any on-campus activities or interactions, the COVID-19 vaccination is not required.
If a student is not fully vaccinated, or has not completed the entire vaccination process, or if you’d like to learn about how to receive a COVID-19 vaccination, visit sunyjcc.edu/covid19 to learn about specific guidelines.
Medical Exemption: Students who are medically advised not to receive the COVID-19 vaccine by their physician, nurse practitioner, or physician’s assistant must provide this information in writing. This document must be signed by the licensed healthcare provider and submitted to their JCC campus Health Center. Students who submit a medical exemption will be subject to additional requirements.
Religious Exemption: Students who hold genuine and sincere religious beliefs which are contrary to receiving the COVID-19 vaccination may be exempt after submitting a written statement as required by a SUNY facility. The statement should explain how receiving the COVID-19 vaccination conflicts with the student’s sincere religious belief or practice and how not receiving the COVID-19 vaccination will not otherwise prevent the student’s completion of the requirements of their academic program.
General, philosophical, or moral objections to such vaccines shall not suffice as the basis for a religious exemption. Students granted a religious exemption will be subjected to certain restrictions and may be subject to other restrictions imposed by the campus.
Additional Considerations for Students with Exemptions: Students who are granted a medical or religious exemptions, and who will be accessing a SUNY facility without first receiving a COVID- 19 vaccination, will be required to quarantine for at least ten (10) days upon arrival and be subject to mandatory weekly COVID-19 testing administered by the campus. Following quarantine, the student will be required to maintain a six (6) feet social distance and wear a mask at all times, indoors and outdoors.
Exceptions to the mask wearing requirement include when students are in their private residential or personal space, eating meals on-campus while seated and social distancing is appropriately enforced, or by themselves.
Campuses may impose additional restrictions as needed.
If you are taking six or more credit hours at Jamestown Community College, you must submit to Health Services:
- MMR/Meningitis Form (includes immunization records for measles, mumps, and rubella (MMR) and meningitis response form with your choice regarding the voluntary meningitis vaccination)
Residence Life health history form
If you live in the residence halls on campus, you must also submit:
Nursing & OTA forms
Nursing and OTA programs require additional immunizations:
- Varicella (Chicken pox or positive Titer)
- Hepatitis B: Clinical sites request that you educate yourself about Hepatitis B. You are at an increased risk in the clinical setting at being exposed to Hepatitis B and other diseases. Get updated vaccination for Hepatitis B or sign the declination on your JCC health report form that you'll receive through your program.