Meningococcal Meningitis Response Form
SUNY Empire State College maintains compliance with New York State Public Health Law 2167
which requires colleges and universities to provide information about meningococcal disease
and vaccination to all students, regardless of age, and maintain a meningitis vaccination record
or signed response form for each student enrolled for at least six (6) semester hours or the
equivalent per semester.
SUNY Empire State College’s policy regarding NYS Public Health Law 2167 is to inform applicants of
the requirement at the point of application/admission to the college and to registered students at
the beginning of each term.
We require that you:
1. Review Information about Meningococcal Meningitis located at www.esc.edu/immunizations and
2. Submit vaccination records verifying you have had at least one dose of meningococcal ACWY
vaccine within the last five years or a complete two-or-three dose series of MenB or
3. Decline vaccination against meningococcal meningitis with your printed name, signature,
date of birth, date and student ID# below.
I, (print) __________________________________________________________, have read, or had explained to me,
the information regarding meningococcal disease located at www.esc.edu/immunizations.
I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization
against meningococcal meningitis.
____________________________________________________________ ________________________________________
Student signature Student date of birth MM/DD/YYYY
____________________________________ ________________________________________
Date Student ID#
SUBMIT THIS FORM AND ALL SUPPORTING DOCUMENTATION TO
immunizations@esc.edu or fax 518-587-9759
Admissions | 111 West Ave. | Saratoga Springs, NY 12866-6069 | 518-587-2100 | fax 518-587-9759 | www.esc.edu
F-610–5/2019
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