New York State Public Health Law (NYS PHL 2167, effective August 15, 2003) requires every Cornell University student who is enrolled for six or more credit hours to complete and submit this form to Gannett: Cornell University Health Services.

Failure to comply with this law will result in registration holds and financial penalties.

If you are under 18, your parent must complete a paper form and send it to Gannett. We are unable to accept the on-line form from parents.

Immunization Information

Check one only

I had the meningococcal disease immunization (Menomune™) within the past 10 years.

Date Received: / / (mm/dd/yyyy)

If you received the meningococcal vaccine at Gannett or if you provided meningococcal vaccine information on your Health History form when you entered Cornell, you do not need to enter the date here.

I read, or have had explained to me, the information regarding meningococcal disease. I will obtain immunization against meningococcal meningitis within 30 days from my private health care provider or Gannett: Cornell University Health Services.

I read, or have had explained to me, the information regarding the meningococcal disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization against meningococcal disease.

Student Information

First Name

Last Name

Student ID (CUID) or Social Security Number

Date of Birth (mm/dd/yyyy)