Appendix E -- Sample College Meningococcal Meningitis Vaccination Response Form
[Copy Onto Your College / Health Service Letterhead]
Sample College Meningococcal Meningitis Vaccination Response Form
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 the following form to [enter name of college/university health center].
Check one statement and sign below.
I have (for students under the age of 18: My child has):
________ had meningococcal meningitis immunization within the past 10 years.
Date received: _________________________________________
[Note: If you (your child) received the meningococcal vaccine available before February 2005, called Menomune™, please note this vaccine's protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate vaccine, called Menactra™, should be considered within 3-5 years after receiving Menomune™.]
________ read, or have had explained to me, the information regarding meningococcal meningitis disease. I (my child) will obtain immunization against meningococcal meningitis within 30 days from my private health care provider or [Enter Name Of College Health Center Or Other Health Facility ].
________ 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 that I (my child) will not obtain immunization against meningococcal meningitis disease.
Signed _________________________________________________________________________ Date _____________________________________________
(Parent / Guardian if student is a minor)
Print Student's Name ______________________________________________________________ Student Date of Birth ________________________________
Student E-Mail Address ____________________________________________________________ Student ID#________________________________________
Student Mailing Address _____________________________________________________________________________________________________________
Student Phone Number ___________________________________________________________
May 5, 2005