Life Science Building, Room 154
720 Northern Boulevard
Brookville, NY 11548-1300
Phone: 516-299-2345 | Fax: 516-299-4113
Emergency: 516-299-2222 (Public Safety)
Immunization Policy - Medical Forms
Immunization Policy, Immunization and Meningitis Information
Center for Healthy Living staff members are dedicated to ensuring the overall health and welfare of our campus community. Therefore, compliance with New York State Public Health Laws (NYSPHLs) 2165 and 2167 is strictly enforced. To simplify this legal process, we have consolidated forms for MMR/Meningitis into one form which, when properly completed, will satisfy requirements.
• Section one covers required demographics.
• Sections two and three are dedicated to New York State Public Health Law 2165 requirements for proof of immunity to Measles, Mumps and Rubella.
• Section four and the entire back page are devoted to New York State Public Health Law 2167 requiring distribution of information, documentation of vaccination and/or waiver for Meningitis.
• Legal requirements for both laws are conveniently outlined on the form for you and your provider.
Submission of completed MMR/Meningitis Form is preferred prior to or at the time of registration. Registered students who are noncompliant with NYSPHLs #2165 and #2167 on the first day of classes will have an H02 and or H09 block placed on their accounts. These blocks will prevent any additional enrollment activity until missing documents are received. If complete immunization documentation is not received within 30 days of the first day of classes, students with such blocks will be suspended from campus and will not be allowed on campus until cleared by the Center for Healthy Living.
Students who are suspended from campus due to immunization noncompliance will be responsible for all financial obligations including but not limited to: full tuition and all applicable fees, room and meal fees and/or loss of access to campus services.
Report of Health Evaluation/ Report of Medical History
The Report of Health Evaluation must be submitted by all Resident students and Athletes. Athletes must submit one copy to the Center for Healthy Living and one copy to the Athletic Department. All forms must be signed and stamped by the physician or they will not be accepted. These forms should be submitted prior to the student’s arrival on campus.
All students must submit their MMR/Meningitis and Immunization History form. This form must be signed and stamped by a physician or it will not be accepted. This record should be submitted prior to the student’s arrival on campus.