DOCUMENTATION OF COVID-19 VACCINES - STUDENTS
DOCUMENTATION OF COVID-19 VACCINES - STUDENTS
Status
Status
Not Completed
Completed By/Date
Completed By/Date
Your Information
Name
Name
*
First
Middle
Last
Date of Birth
Date of Birth
*
/
MM
/
DD
YYYY
Student ID Number ("A" Number)
Email
*
Phone
Phone
*
-
###
-
###
####
Date of first COVID-19 vaccine
*
Date of second COVID-19 vaccine
*
Vaccine Manufacturer:
Vaccine Manufacturer:
Pfizer
Moderna
I don't know
Other
Other
PLEASE UPLOAD DOCUMENTATION OF VACCINES
*
Attach Files
Draw your signature into the box below. (Note: If you are under 18 a parent/guardian must sign.)
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or
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Full Name
I understand this is a legal representation of my signature.
Thank you for submitting your COVID-19 vaccine records.
A member of our staff will review and record the information within the next 3-5 business days. You may check your student Banner record to confirm receipt.
There are two ways to access your information on Banner:
1.) Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "I" then choose "Immunizations."
OR
2.) 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.
The Wellness Center Staff