DOCUMENTATION OF COVID-19 VACCINES - STUDENTS

Status

Status Not Completed Completed By/Date Completed By/Date
Are you a student (current or prospective)? *

Are you a student (current or prospective)? Yes No
Instructions for Employees

Employees must submit documentation of COVID-19 vaccines to Human Resources via this link:
EMPLOYEES DOCUMENTATION OF COVID-19 VACCINES
Name Name * First Middle Last
Your Information
Date of Birth Date of Birth * / MM / DD YYYY
Student ID Number ("A" Number)
Email *
Phone Phone * - ### - ### ####
Vaccine Manufacturer:

Vaccine Manufacturer: Pfizer Moderna Janssen Other Other
Date of first COVID-19 vaccine
Date of second COVID-19 vaccine
Date of Booster
PLEASE UPLOAD DOCUMENTATION OF VACCINES
JPEG photo or PDF files only!
Note: The Excelsior Pass is not acceptable. The records must state your name, Date of Birth, Issuing Agency, Type of Vaccine and Dates of Vaccine. *

Attach Files
Draw your signature into the box below. (Note: If you are under 18 a parent/guardian must sign.)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Thank you! This is your notice that your records have been received. Please allow 3-5 business days for processing. You will be contacted again only if there is an issue with your records.

To check the status of your records here's how to view them in your student Banner account:

A. Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "I" then choose "Immunizations."
OR
B. Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "S" then choose "Student Profile," then click on the immunizations link in the left navigation.

Wellness Center Staff

DOCUMENTATION OF COVID-19 VACCINES - STUDENTS

DOCUMENTATION OF COVID-19 VACCINES - STUDENTS

Instructions for Employees

Your Information