Additional Forms & Information

The Western Health Center can provide students with most vaccines they will need to maintain a healthy lifestyle including the flu shot and the HPV vaccine. We recommend you call the Health Center at 943.2707 for pricing and scheduling. if you are traveling to a foreign country and require Typhoid, Cholera, or Yellow Fever vaccinations please contact the Montrose Public Health Dept. at 970.252.5000 for information regarding those vaccinations.

There is an abundance of information available at the CDC website www.cdc.gov/vaccines. From there you can browse their page and visit sites that will answer vaccination questions, lead you to links about international travel and much, much more. For information regarding a specific vaccine click on Vaccine Information Statements (VIS). From there you can click on individual vaccines.

Helpful Links for Specific Vaccinations

Human Papilloma Virus:

• www.cdc.gov/STD/hpv
• www.GARDASIL.com
• www.HPV.com

Hepatitis A-E:

• www.webmd.com/hepatitis
• www.cdc.gov

Influenza:

• www.cdc.gov/flu

Preventing the Flu:

• www.cdc.gov/flu/protect

Meningitis Disease Information:

• www.meningococcaldisease.com

Tetanus, Pertussis, Diptheria Booster (Tdap) for adolescents:

• www.tetanus.org
• www.cdc.gov/vaccines/vpd-vac

More vaccine information…

• http://www.vaccines.com/

You can enter or update your Emergency Contact Information from your MyWestern page. It is your responsibility to keep this information up-to-date and accurate.

To enter your Emergency Contact Information:

1. Sign in to your MyWestern Account
2. Click on the Personal Information tab at the top
3. Click on View Emergency Contacts
4. Follow instructions to enter the appropriate information

Contact the Office of Student Affairs at 970.943.2232 if you have trouble with this form.

For health and safety reasons, as well as compliance with Colorado law and State Health Department regulations, all students enrolled in colleges and universities are required to submit proof of immunization*.  In the event of an outbreak, Western needs to be able to respond appropriately and timely.  For this to be effective, we need ALL students to comply.  Students must submit the completed CERTIFICATE OF IMMUNIZATION FOR COLLEGE STUDENTS or STATEMENT OF EXEMPTION form to Student Affairs before registration.  To make sure we have full student compliance, holds will be put on student accounts who have not provided us with proof of 2 MMR immunizations.  Holds will also be placed on student accounts for those living on-campus and are missing the meningococcal vaccination or waiver.

Age Exemption
*Measles, mumps, and rubella (MMR) vaccine is not required for college students born before January 1, 1957.

A college student is defined by the State Board of Health as any student who is enrolled for one or more classes at a college or university and who is physically present at the institution. Students who are auditing classes are included, but students who are taking only correspondence or off-campus classes are not included.

Early each semester, all students who are not in compliance will be notified by email and it will be noted on their checklist in MyWestern.

If your proof of immunity is incomplete, contact the Campus Health Center located on the first floor of Tomichi Hall or Public Health to obtain the necessary immunizations. The MMR immunization is usually given to children at age 1 and 5. We are not asking that you get an additional immunization if you have already had these shots. We only need proof that you have had them. Proof can be provided on an immunization record that is signed by a doctor, a record that has been printed directly from a provider or insurance company’s electronic record, or from a previous school. More than likely, your high school also required these shots. A record from your high school will most likely be accepted. A hand-written, personal copy is not sufficient unless it includes some kind of signature or stamp from the clinic/doctor that administered the vaccination. Some states have a database that you may be able to use to locate your past immunizations.

If you need to get the immunization, Public Health in Gunnison (970.641.0209) does offer the immunization. Under the Affordable Care Act, if you have insurance, immunizations are provided at no cost. Without insurance, the immunization cost is $14 per shot. A titer test can be taken at the Gunnison Valley Hospital, which will show if you have been immunized before. A positive titer would mean that you have been immunized and you would only need to provide the positive titer results instead of proof of 2 MMRs. However, a titer test is significantly more expensive. It is not harmful to get re-immunized if you have had the shots before. If there is no record of the immunizations, we have to assume they never happened.

Please print the form below and send it to the Office of Student Affairs. You may call the Campus Health Center at 970.943.2707 if you have questions regarding this vaccination.

• Immunization Form (click on “Certificate of Immunization for college/university students”) -> please print and sign. Please do NOT use a digital ID signature.

Western Colorado University strongly recommends that all students receive the meningitis vaccination. However, Colorado state law indicates that only first year students are required to provide proof or a waiver of the meningitis vaccination.  A meningitis vaccination must have been given within the past five (5) years, otherwise a booster is required.  If a student decides not to obtain the booster and their previous vaccination is more than five (5) years old, they must sign the waiver (pg. 2 of the Certificate of Immunization). Students interested in getting the meningitis vaccine should contact their health care provider or contact Gunnison County Public Health at 970.641.0209 to make an appointment. First year students and students living in on-campus housing will be asked to read and acknowledge information regarding the meningitis vaccine when completing their housing contract online before moving into their residence hall and all students are required to sign a waiver if they chose not to receive the vaccination.

*PLEASE NOTE: The immunization form has two (2) pages.  You only need to fill out the Meningococcal Disease side if you have decided NOT to obtain the vaccination or your most current shot is more than five (5) years old and you have chosen not to get a booster, in which case, please check the box and fill in the information requested.  If you have received the vaccination, please fill in the date it was received on the 1st page and ensure that you have at least read the Information Regarding Meningococcal Disease.

• Immunization FAQs

By completing this form, you are consenting to the disclosure of any personally identifiable information from your educational records to the person(s) you identify, for reasons determined by Western Colorado University as appropriate.

Be sure to read all information about what you are giving permission for before submitting.  If you have any questions, please contact the Office of Student Affairs at 970.943.2232 or by email at sbains@western.edu.

To submit a Release of Academic Information:

1. Sign in to your MyWestern Account
2. Click on the Student tab at the top
3. Click on Student Records
4. Click on Academic Record Release
5. Follow the instructions to enter your information

The Selective Service System is what provides our nation with the structures and guidelines for a draft, in the event that the country would need one. Registration with Selective Service is a federal law and is required by all males ages 18-25. As a student you must be registered to be eligible for FSA funds.

Download the Selective Service Form

Not sure if you’ve already registered?

• To check your registration go to Selective Service’s website and click “Check a Registration.”

Haven’t registered yet?

• You may register at your local post office or at Selective Service’s website.

Not 18 yet?

• If you have not yet turned 18, Western still needs you to complete and turn in the Certification of Selective Service Registration form. Check the box that says “I have not reached my 18th birthday” and sign. Remember that you will need to complete a new form verifying that you have registered once you turn 18.

Selective Service’s website is very informative and is a great resource to answer any questions you may have about Selective Service.

When you are sure that you have registered, please fill out our Certification of Registration form and return it to the Student Affairs Office in Taylor Hall 301 or fax it to 970.943.2254. We do not need a copy of your registration number that you receive as confirmation of your registering; keep that for your records.

***Email sbains@western.edu for the Certification of Registration form or stop by the Office of Student Affairs in Taylor Hall 301. This form is also emailed out to all new students before Orientation.***

Instructions for Completion of Incident/Injury/Property Damage Report

To be completed by Student/Witness/Other

This is not a report for on-the-job injuries. Use the first report of injury from provided by the HR office.

1. Report all serious injuries and safety hazards to campus security ext. 3084, student affairs ext. 2232, and risk management office ext. 7052.
2. Report all Incident/Accident within 24 hours.
3. Individuals involved in, observing or discovering the Incident/Accident or property damage is responsible for completing this report.
4. Be observant: attempt to get as much information as possible at the time of the Incident/Accident.
5. Relate only to the facts on this form.
6. The Student Affairs Office will review this Incident/Accident report and will submit it to the Risk Management Manger with any recommendations for action, if necessary.
7. After form is completed, email or deliver this form to student affairs office at gpierson@western.edu or hand deliver a hard copy to:
   Taylor Hall 301
   1 Western Way
   Gunnison, CO
8. Once Student Affairs reviews the report, it will be determined if a student Incident/Accident Analysis form will need to be filled out by the department head.