Required Immunization History Form
ALL new first-year, transfer, graduate, and international students must submit the ESF Immunization History Form.
Download FormImmunization History Form (PDF)
Mail, Email or Fax
Crouse Medical Practice
739 Irving Avenue
Suite 300, ESF Clinic
Syracuse NY 13210
FAX - 315-766-1614
Your Immunization History Form must be submitted by:
- August 1 (for Fall admits)
- January 2 (for Spring admits)
Per New York State law, we are required to collect this information.
Pursuant to NYS Public Health Law § 2167, all students regardless of age, must read and certify that they have been informed about meningitis.
Any student who believes they should be exempt from the immunization requirements must follow the directions on page 3 of the Immunization History Form before the deadline to request an exemption.
Failure to submit the ESF Immunization History Form by the identified deadline may result in your class schedule being cancelled.