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rior to first birthday.
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Month Day Year
Month Day Year
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Month Day Year
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Month Day Year
STUDENT IMMUNIZATION RECORD FORM
Immunization records are required prior to registration.
Please complete this form and return it to Office of Health Services Medical Arts, Room MC-02 or fax to: 718 631-6330.
Document must be legible to be processed. Students are responsible for obtaining an official translation of foreign records prior to
submission. Students born prior to January 1, 1957 are exempt from the measles, mumps, and rubella requirement.
All students must also complete “Part 3: Meningococcal Meningitis Vaccination Response” on second page.
Part 1: Student Information
Name (please prin
Date of Birth _______ /_______ /_______________ CUNYFIRST ID No. _______________________________
Daytime Phone: ( ________ ) ________ - ___________________ E-mail Address: __________________________________________________
Information to Complete Immunization Requirements
Measles, Mumps, Rubella:
New York State Public Health Law 2165 requires all students entering a post-secondary institution to provide their health services
center with proof of immunity to measles, mumps and rubella. This law applies to students born on or after January 1, 1957.
ACCEPTABLE PROOF OF IMMUNITY MAY INCLUDE:
1. Immunization cards from childhood (yellow card), signed and stamped by medical provider.
2. Immunization records from college, high school or other schools you attended with school stamp.
3. Signed and stamped immunization record from your health care provider or clinic. Note: Immunization records obtained from a
public health department immunization information system. Students born after 1994 who were raised in New York City can check
the Citywide Immunization Registry for their records by calling 311.
4. Copy of lab report with correct name and date of birth, showing immunity to measles, mumps and rubella (also known as titer or
serology).
If you attended a CUNY college, your immunization record will be available at your new school.
Part 2: Immunization History
To be completed by a health care provider. Documentation must be included.
Provider: All dates must include month, day, and year. Please mark an (X) in the appropriate boxes.
Measles, mumps and rubella must be live vaccine and given no more than 4 days p
MMR (
o D
measles, mumps, rubella) – if given as combined dose instead of individual vacci
ose 1: No more than 4 days prior to first birthday, AND on or after April 23, 197
Dose 2: At least 28 days after first vaccine
OR
TITER (b
o Me
lood test) showing positive immunity (Dated lab results MUST be attached
asles
o Mumps
o Rubella
Health care provider information (Please include official stamp.):
Name: ______________________________________________________ Title: ________
Address: ___________________________________________________________________ Pho
ne: ( _______ ) ____________________________
Signature: __________________________________________________________________ L
icense No.: _________________________________
Fax: ( _______ ) ____________________________
click to sign
signature
click to edit
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