Immunization Waiver for Online Only Students
Students who are registering for online courses only, and will NOT physically attend classes on any of UB’s
campuses, can request a waiver of the immunization requirements. To register for online courses again during
a subsequent semester, a new waiver must be completed and submitted. Allow 2-3 business days, upon receipt,
for processing. The effective date of the IMM hold will be future dated when the waiver is processed. The MEN
hold will be removed when the waiver is processed.
Application for Measles, Mumps, Rubella Waiver
To apply for the Measles, Mumps, Rubella Wavier, please read and complete below.
I will be taking ONLY online courses at University at Buffalo for the identified semester.
I understand that I still need to comply with the Meningitis education requirement. This can be done by
completing the lower portion of this form or online through the HUB Student Center.
I understand that if I want to register for any classes that require my physical attendance on campus, I must
comply with the immunization requirements prior to registration.
I understand that if I want to register for online courses again during a subsequent semester, I will need to
request a new waiver.
Meningitis Waiver
To comply with the Meningitis education requirement, please read and complete below.
In accordance with New York State Public Health Law, all University at Buffalo students must fulfill the
requirement to complete the Meningitis Information Response Form.
Circle one of the two statements and sign below.
I have had the meningococcal meningitis immunization within the past 5 years (if the student has received the
vaccine, it is required to provide the date received).
Date received (MM/DD/YYYY):
I have read, or have had explained to me, the information regarding meningococcal meningitis disease.
I understand the risks of not receiving the vaccine. I have decided I will not obtain immunization against
meningococcal meningitis disease.
THE FOLLOWING SECTION IS REQUIRED. FORMS WILL NOT BE ACCEPTED UNLESS ALL FIELDS ARE COMPLETED.
Name:
Birthdate:
Person Number:
Semester/Term:
Signature:
Date:
Continue to page 2
