Immunization Requirement Form

IMMUNIZATION REQUIREMENT FORM
Part One: Student Information
STUDENT ID NUMBER LAST NAME FIRST NAME MIDDLE
DATE OF BIRTH FIRST SEMESTER AT PACE PACE E-MAIL ADDRESS

New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester hours or the equivalent
per semester, or at least four (4) semester hours per quarter, complete and return this form to Pace University.
. Please submit copies of all supporting documentation and keep originals for your records.
Please print legibly. All documentation must be in English.
This part must be certified by a health care provider, with an official stamp and/or license
Part Two: Measles, Mumps, Rubella number indicated below
VACCINATION DATES: Two Measles vaccinations, one Mumps vaccination, and one Rubella vaccination must have been given after the
student’s first birthday. Please have your health care provider indicate the dates appropriately and certify the form below:
MMR Dose #1: / / Measles Dose #1: / / _ Rubella Dose #1: / /
MMR Dose #2: / / Measles Dose #2: / / _ Rubella Dose #2: / /
MEDICAL HISTORY: If you have history of contracting either Measles or Mumps disease, please have your health care provider indicate the
date(s) appropriately and certify the form below:
Measles Disease: / / Mumps Disease: / /
EXEMPTION FROM MEASLES, MUMPS, and RUBELLA VACCINATION (student must legibly check the applicable box):
1) Birth Exception (born prior to January 1, 1957):

2) Medical Exception (circle either Temporary or Permanent, submit medical documentation):
3) Religious Exception (student with deeply held aversions to receiving vaccinations for religious reasons must submit a formal, signed and
dated original statement, indicating such):
BLOOD ANTIBODY TITER TEST: Students must submit a dated laboratory report to be considered compliant through this option. The
report must include the laboratory name and address, the student’s name and date of birth, the numerical result(s), and the numerical interpretation
ranges.
HEALTH CARE PROVIDER INFORMATION:

Name (Print):
Signature:
Phone Number:
Part Three: Meningococcal Meningitis Place Official Stamp and/or License Number of Health Care Provider Above
This part is not optional, all students must fill this part out. You must check ONE of the TWO boxes and MUST SIGN BELOW to be compliance
with NYSDOH Public Health Law 2167. If the fist box is chosen, a valid date must be indicated. For students under the age of 18, signature of
parent or guardian is also required.
I have had the meningococcal immunization within the past 5 years of my first date of enrollment at Pace University.
The date of the shot was / /
I have read or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving
the vaccination. I have decided that I (my child) will not obtain immunization against meningococcal disease.
STUDENT’S SIGNATURE DATE PARENT/GUARDIAN’S SIGNATURE DATE

OFFICE USE ONLY OSA REP: DATA ENTERED: MISSING INFO: YES / NO Updated 3/2021
Instructions for the Immunization Requirement Form
Return the signed and completed form online through the Patient Portal at:
www.pace.edu/patientportal
Please contact Medicat Compliance Services by email at [email protected] with

questions regarding your immunization document submission.
Return by the following dates:
Fall Term: August 1 | Spring Term: December 1 | Summer I Term: May 1 | Summer II Term: June 1
PART ONE: To be filled out completely by the student. Please make sure to provide us with your Student Identification Number, a phone number(s)
you can be reached at, and your Pace assigned e-mail address.
PART TWO: MEASLES, MUMPS, RUBELLA (MMR): To be completed by your healthcare provider. Supporting documentation is not required
if this part is signed and stamped legibly.
New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester hours or the equivalent per
semester, or at least four (4) semester hours per quarter, complete and return.
You must provide proof of having received 2 measles, 1 mumps, and 1 rubella vaccinations. The dates of these vaccinations must be indicted
in the part and all vaccinations must have been received on or after your first birthday.
Please note that any supporting documentation must have been either signed or stamped by a hospital or medical provider or, in the case of prior
high school or university records, stamped by an official of that institution. An original signature or stamp must appear on the documentation.
ALL SUPPORTING DOCUMENTION MUST CLEARLY SHOW THE DATES OF VACCINATIONS ON THEM.
If you have had either the measles or the mumps in the past, no proof of vaccination will be necessary. However we will require that the dates when
you contracted the disease be verified by a health care provider or it will not be accepted.
Another option is taking a Blood Antibody Titer Test and submitting a dated laboratory report. This report must include the laboratory name and
address, the student’s name and date of birth, the numerical result(s), and numerical interpretation ranges. Equivocal results reflect negative
immunity.
If you were born prior to January 1. 1957, please check the Birth Exception box. We will verify your birth date against the information available in
your student academic record.
PART THREE: MENINGOCOCCAL MENINGITIS: To be filled out completely by the student.
On July 22, 2003, Governor Pataki signed New York State Public Health Law (NYS PHL) 2167 requiring institutions, including colleges and
universities, to distribute information about meningococcal disease and vaccination to all students meeting the enrollment criteria, whether they live
on or off campus.
Pace University is required to maintain a record of the following for each student:
• Certificate of Immunization for meningococcal meningitis disease; or

• A response to receipt of meningococcal meningitis disease and vaccine information signed by the student or the student’s parent or
guardian; AND EITHER
• Self-reported or parent recall of meningococcal meningitis immunization within the past 5 years; or
• An acknowledgement of meningococcal disease risks and refusal of meningococcal meningitis immunization signed by the student or
student’s parent or guardian.
Resident first-year students are strongly encouraged to receive a meningitis vaccination.
Students in a nursing program or a physician assistant program must complete this part of the form and submit with a copy of the blood titer
results required for participation in those programs.
The University Health Care (UHC) Office can assist you in fulfilling these requirements. Inoculations can be administered for Measles, Mumps, and
Rubella (MMR). The Meningitis vaccine may be available. You may contact them directly at the numbers below to make an appointment.
New York UHC (212) 346-1600 Westchester UHC (914) 773-3760
Updated 3/2021

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Part One: Student Information

STUDENT ID NUMBER LAST NAME FIRST NAME MIDDLE

DATE OF BIRTH FIRST SEMESTER AT PACE PACE E-MAIL ADDRESS

MMR Dose #1: / / Measles Dose #1: / / _ Rubella Dose #1: / /

MMR Dose #2: / / Measles Dose #2: / / _ Rubella Dose #2: / /

Measles Disease: / / Mumps Disease: / /

1) Birth Exception (born prior to January 1, 1957):

HEALTH CARE PROVIDER INFORMATION:

STUDENT’S SIGNATURE DATE PARENT/GUARDIAN’S SIGNATURE DATE

Please contact Medicat Compliance Services by email at [email protected] with

Return by the following dates:

PART THREE: MENINGOCOCCAL MENINGITIS: To be filled out completely by the student.

• Certificate of Immunization for meningococcal meningitis disease; or

Resident first-year students are strongly encouraged to receive a meningitis vaccination.

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