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 print):
Thiha Khant Zaw Last Name First Name Middle Initial
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 prior to first birthday. MMR (measles, mumps, rubella) – if given as combined dose instead of individual vaccine. o 11/11/2007 ✔ Dose 1: No more than 4 days prior to first birthday, AND on or after April 23, 1971 Month Day Year Dose 2: At least 28 days after first vaccine 10/28/2024 OR Month Day Year
TITER (blood test) showing positive immunity (Dated lab results MUST be attached) ✔ o Measles 11/11/2007 Month Day Year ✔ o Mumps 11/11/07 Month Day Year ✔ o Rubella 11/11/2007 Month Day Year
Health care provider information (Please include official stamp.):
Dr. Khin Su Mar Name: ______________________________________________________ Mrs Title: ________
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.
Part 3: Meningococcal Meningitis Vaccination Response
To be completed by the student. Please check one box in Section A below, and sign & date in Section B. A. I have (for students under the age of 18: My child has): o ✔ had meningococcal immunization within the past 5 years. The vaccine record is attached. [Note: The Advisory Committee on Immunization Practices recommends that all first-year college students up to age 21 years should have at least 1 dose of Meningococcal ACWY vaccine not more than 5 years before enrollment, preferably on or after their sixteenth birthday. In addition, that young adults aged 16 through 23 years may choose to receive the Meningococcal B vaccine series. College and University students should discuss the Meningococcal B vaccine with a Healthcare Provider.]
o ✔ read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal disease. B. 10/29/2024 Student/or Parent Signature if student is under 18 years of age
More Information How do I get more information about meningococcal disease and vaccination? • Contact your primary care provider or your Student Health Services at 718 631-6375 or visit our website at: www.qcc.cuny.edu/healthservices Additional information is also available on the following websites: • www.health.state.ny.us (New York State Department of Health) • www.cdc.gov/vaccines/vpd-vac/ (Centers for Disease Control and Prevention) • www.acha.org (American College Health Association)
To Submit Immunization Records:
Mail to: QCC- Office of Health Services Medical Arts Building, Room MC-02 222-05 56th Avenue Bayside NY 11364
Medication A.R.E.A.S. Bundle: A Prescription for Value-Based Healthcare to Optimize Patient Health Outcomes, Reduce Total Costs, and Improve Quality and Organization Performance
