STUDENT IMMUNIZATION REQUIREMENTS AND MENINGITIS RESPONSE FORM

Students entering college in New York State are required to submit proof of immunity to Measles, Mumps, and Rubella (MMR). They must also complete the Meningitis Response Form. COVID-19 vaccinations are optional at this time, but are highly encouraged. If you do have your COVID-19 vaccinations, please include that information, as the requirement may change in the future.

Status

Status Not Completed Completed By/Date Completed By/Date
Student Information
Student's Name Student's Name * First Middle Last
Date of Birth Date of Birth * / MM / DD YYYY
Student ID ("A" Number)

Leave blank if you do not know or do not yet have a student ID number.
Email *

It is recommended you use your sunyorange.edu email account to ensure security of records submitted via the internet.
Phone Phone * - ### - ### ####
IMMUNIZATION REQUIREMENTS

Submit your Immunization Record below, after the Meningitis Response section.

IMMUNIZATION HOLDS are attached to all student accounts and will be removed when records are received and accepted. You may view this information in your student account (see below).
MMR (Measles, Mumps, Rubella)

New York State Public Health Law Section 2165 requires that Students born on or after January 1, 1957 submit proof of immunity to measles, mumps, and rubella.

Only one of the following is required:

Proof of two doses of live measles, mumps, and rubella vaccine (MMR), the first dose given no more than 4 days prior to the first birthday and the second at least 28 days after the first dose;

OR

Proof of two doses of live measles vaccine, the first dose given no more than 4 days prior to the first birthday and the second at least 28 days after the first dose, AND one dose of live mumps vaccine received no more than 4 days prior to the first birthday, AND one dose of live rubella vaccine received no more than 4 days prior to the first birthday;

OR

Serological proof of immunity (titer) to measles, mumps, and rubella (demonstration of measles, mumps, and rubella antibodies through a blood test performed by an approved medical laboratory)

All immunization records must include the student's full name and date of birth. Records from healthcare providers must include the healthcare provider's name, signature, and location. Records from high schools, colleges, universities and healthcare facilities must include the name and address of the institution.

View the New York State Health law here.
COVID-19

Beginning with the Summer 2023 Semester, COVID-19 vaccines are no longer required by SUNY schools for in-person
attendance. However, the Wellness Center will still be collecting your vaccine dates if you have been vaccinated, as this
policy is still subject to change in the future. When you are uploading your immunization records, please include your COVID-
19 vaccine dates if applicable.
We highly encourage everyone to keep up on their COVID-19 vaccines, as vaccination is the best protection from this highly
contagious disease. COVID-19 is still rapidly spreading, and we have no way of knowing if the SUNY Vaccination Policy will
change in the future.
*Please note that if you are going to be participating in an internship or clinical practicum outside of SUNY Orange, you will
be required to follow the requirements of the outside setting.
MENINGOCOCCAL DISEASE FACT SHEET

New York State Public Health Law Section 2167 requires post-secondary institutions to distribute information about meningococcal disease and vaccination to all students, or parents or guardians of students under the age of 18. The institution is required to maintain a record of the following for each student: a response to receipt of meningococcal meningitis disease and vaccine information signed by the student or the student's parent or guardian, and either a certificate of immunization for meningococcal meningitis disease OR an acknowledgement of meningococcal disease risks and refusal of meningitis immunization.

Find out more by visiting NYS Public Health Laws

A Meningitis Hold is placed on all student accounts until the Meningitis Response Form is received.

PLEASE READ THE MENINGITIS DISEASE FACT SHEET BELOW AND RESPOND.

THE VACCINE IS OPTIONAL, BUT A RESPONSE IS REQUIRED.

MENINGOCOCCAL DISEASE FACT SHEET

What is meningococcal disease?

Meningitis is a serious illness caused by a type of bacteria called Neisseria meningitidis. It can lead to meningitis (infection of the lining of the brain and spinal cord) and infections of the blood. Meningococcal disease often occurs without warning—even among people who are
otherwise healthy. There are at least 12 types of N. meningitidis, called “serogroups.” Serogroups A, B, C, W, and Y cause most meningococcal disease.

How is meningococcal disease spread?

Meningococcal disease can spread from person to person through close contact (coughing or kissing) or lengthy contact, especially among people living in the same household.

What is the best way to prevent meningococcal disease?

The single best way to prevent this disease is to be vaccinated. Meningococcal ACWY vaccines can help prevent meningococcal disease caused by serogroups A, C, W, and Y and serogroup B meningococcal (MenB) vaccines can help prevent meningococcal disease caused by serogroup B. Meningococcal ACWY Vaccines There are two kinds of meningococcal vaccines licensed by the Food and Drug Administration (FDA) for protection against serogroups A, C, W, and Y: meningococcal conjugate vaccine (MenACWY) and meningococcal polysaccharide vaccine (MPSV4). Two doses of MenACWY are routinely recommended for adolescents 11 through 18 years old: the first dose at 11 or 12 years old, with a booster dose at age 16. Serogroup B Meningococcal Vaccines Two serogroup B meningococcal vaccines—Bexsero® and Trumenba®—have been licensed by the Food and Drug Administration (FDA). For best protection, more than 1 dose of a serogroup B meningococcal vaccine is needed. The same vaccine must be used for all doses. Ask your health care provider about the number and timing of doses.

Who should receive the vaccine?

In addition to routine vaccination for adolescents, the vaccine is also recommended for certain groups of people:

People at risk because of a meningococcal disease outbreak;

Anyone whose spleen is damaged or has been removed;

Anyone with a rare immune system condition called “persistent complement component deficiency”;

Anyone taking a drug called eculizumab (Solaris®);

Microbiologists who routinely work with isolates of N. meningititis;

Anyone traveling to, or living in, a part of the world where meningococcal disease is common, such as parts of Africa;

College freshmen living in dormitories;

U.S. military recruits.

Where to obtain the meningitis vaccine:

The vaccine may be obtained from your healthcare provider or a local pharmacy. The Wellness Center does not distribute the vaccine.

Learn more about meningococcal disease: www.cdc.gov/meningococcal/
MENINGITIS RESPONSE *

MENINGITIS RESPONSE I have read and understand the Meningitis Disease Fact Sheet
I have/my child has: *

I have/my child has: Received the meningitis vaccine within the past 5 years. (The vaccine record must be attached.) Not received the vaccine, and have read, or had explained to me, the information regarding meningococcal disease. I understand the risk of not receiving the vaccine. I have decided I will not obtain immunization against meningitis disease at this time.
Please enter the date of the meningitis vaccination and attach records below: Please enter the date of the meningitis vaccination and attach records below: * / MM / DD YYYY

You cannot choose a date that is more than five years ago. The date of the meningitis vaccination MUST BE within the last five years!
PLEASE ATTACH RECORD OF IMMUNIZATIONS.

Attach Files

Records must include proof of immunity to MMR (vaccines or positive titers), COVID-19, and proof of meningitis vaccine if that option is chosen (see above).
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 for submitting your immunization 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

STUDENT IMMUNIZATION REQUIREMENTS AND MENINGITIS RESPONSE FORM

STUDENT IMMUNIZATION REQUIREMENTS AND MENINGITIS RESPONSE FORM

Student Information

IMMUNIZATION REQUIREMENTS

MMR (Measles, Mumps, Rubella)

COVID-19

MENINGOCOCCAL DISEASE FACT SHEET