Immunization Record Form Guide
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 student born after January 1st 1957.
Regardless of your method of attending classes (online, hybrid or remote), students must provide proof of having received two doses of the MMR vaccine and documentation of their most recent dose of the meningitis vaccine. You may do so by either:
- Having your healthcare provider complete the Immunization Record Form, they fill out the 'Health Care Provider Information' section and stamp the form (Stamp must contain name and license number and in English).
- OR, if you have access to your own vaccination history/records, you may complete the Immunization Record Form yourself and submit a copy of your immunization records.
**If you were born BEFORE January 1, 1957, you DO NOT need to submit proof of vaccination for the MMR vaccine. But you may still need to submit a Meningitis Record Form.**
On page one of the immunization record form, you will fill in your Student Information.
*You may find your EMPLID on CUNYFirst. Login to CUNYFirst > Student Center > Profile (it is an 8-digit number)*
If you have received one or two dose of the MMR vaccine then you will fill out part 1A. Part 1A has three sections:
- If you have received the measles, mumps and rubella vaccine as a combined vaccine, MMR vaccine, input your vaccination dates where it says 'MMR dose 1 and dose 2'.
*Your first dose of the MMR vaccine must be given AFTER your first birthday, or no earlier than 4 days Prior to your first birthday*
* You MUST have received two doses of the MMR vaccine in order to be in full compliance. Providing only one dose of the MMR vaccine will place you in partial compliance.*
- The section underneath will be completed only if you have received the measles, mumps and rubella vaccine as individual doses.
Mark the vaccines you have received and provide the dates of vaccination.
If you are completing the form yourself, you must also submit proof of vaccination along with the immunization record form.
- The third section will be completed if have done a titres blood test to check for immunity.
For this section you will input the date of when you did the test (not the day of when you received the results).
You must submit a copy of your lab report so that we may verify immunity. Your lab report MUST contain the following: full name, date of birth, clinic heading, numerical reference range (positive, equivocal, negative) and numerical result value.
Part 1B is to be completed and STAMPED by your healthcare provider certifying vaccinations. If you are filling the form yourself there is no need to complete this section and you may go to the next section.
Part two: Meningitis
Part two will ask about the meningococcal meningitis vaccine (please select ONE option):
If you have received the vaccine within the last 5 years you may mark the 1st box and input the date you received the vaccine. Please be sure to provide proof of vaccination.
*Meningitis vaccine must not be older than 5 years to present date*
*Additionally, even if your doctor completes part 1B of the form, you must still provide proof of vaccination for the Meningitis vaccine*
If you have not received the vaccine within the last 5 years, then you may choose one of the other two options:
*The meningitis vaccine is optional and you are not required to vaccinated against Meningitis to attend CCNY*
Once you have completed part 2 by marking ONE of the boxes, you will sign part 2b (parents must sign if you (the student) are under the age of 18)
You may submit your records in person by stopping by Marshak, Room J-15. Or you may either scan or take a picture of your records and form, and upload them to our secure transfer link: https://securetransfer.ccny.cuny.edu/filedrop/shs@ccny.cuny.edu
If you have any questions, feel free to email us at shs@ccny.cuny.edu or call us at 212-250-8222.
Last Updated: 03/04/2025 16:04