Meningitis Information Response Form
In accordance with New York State Public Health Law, all University at Buffalo students must fulfill the
requirement to complete the Meningitis Information Response Form. Students who are minors must have a
parent/guardian complete the form on their behalf.
Student’s name Student’s
Date of Birth
Student Signature Date
Parent / Guardian (if student is a minor)
UB Person# Phone #
Circle one of the two statements below.
1. The student has had the meningococcal meningitis immunization within the past 5 years (if the student has
received the vaccine, it is required to provide the date received).
Date received (MM/DD/YYYY): _
2. I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I
understand the risks of not receiving the vaccine. I have decided that the student will not obtain
immunization against meningococcal meningitis disease.
The consent section below does not impact your student’s ability to register. However, your signature on
this section allows Health Services to provide medical care to your minor student.
Consent of Parent or Guardian for Treatment of Those Under 18 Years of Age
To be completed if the student is under 18 years of age at the time of arrival on campus even if student will turn 18 during the academic year.
Signature of Parent/Guardian indicates that UB Health Services has permission to treat the student. This
includes care & treatment by medical providers at any outside health care facility if deemed necessary by
UB Health Services.
Parent/Guardian Date
Submit Completed Forms
Via mail:
UB Health Services
Michael Hall
3435 Main St.
Buffalo, NY 14214-8003
Via Fax: 716-829-2564
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