MENINGITIS RESPONSE FORM

New York State Public Health Law Section 2167 requires post-secondary institutions to distribute information about meningococcal disease and vaccination to all students, or parents or guardians of students under the age of 18. The institution is required to maintain a record of the following for each student: a response to receipt of meningococcal meningitis disease and vaccine information signed by the student or the student's parent or guardian, and either a certificate of immunization for meningococcal meningitis disease OR an acknowledgement of meningococcal disease risks and refusal of meningitis immunization.

Find out more by visiting NYS Public Health Laws

A Meningitis Hold is placed on all student accounts until the Meningitis Response Form is received.

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Name Name * First Middle Last
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Do you know your Student ID number ("A" Number)? Yes No
archived STUDENT ID ("A" NUMBER)
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STUDENT ID (A NUMBER)
Date Of Birth Date Of Birth * / MM / DD YYYY
Email *
Phone Phone * - ### - ### ####
PLEASE READ THE MENINGITIS DISEASE FACT SHEET BELOW AND RESPOND. THE VACCINE IS OPTIONAL, BUT A RESPONSE IS REQUIRED.
MENINGOCOCCAL DISEASE FACT SHEET

New York State Public Health Law Section 2167 requires post-secondary institutions to distribute information about meningococcal disease and vaccination to all students, or parents or guardians of students under the age of 18. The institution is required to maintain a record of the following for each student: a response to receipt of meningococcal meningitis disease and vaccine information signed by the student or the student's parent or guardian, and either a certificate of immunization for meningococcal meningitis disease OR an acknowledgement of meningococcal disease risks and refusal of meningitis immunization.

Find out more by visiting NYS Public Health Laws

A Meningitis Hold is placed on all student accounts until the Meningitis Response Form is received.

PLEASE READ THE MENINGITIS DISEASE FACT SHEET BELOW AND RESPOND.

THE VACCINE IS OPTIONAL, BUT A RESPONSE IS REQUIRED.

MENINGOCOCCAL DISEASE FACT SHEET

What is meningococcal disease?

Meningitis is a serious illness caused by a type of bacteria called Neisseria meningitidis. It can lead to meningitis (infection of the lining of the brain and spinal cord) and infections of the blood. Meningococcal disease often occurs without warning—even among people who are
otherwise healthy. There are at least 12 types of N. meningitidis, called “serogroups.” Serogroups A, B, C, W, and Y cause most meningococcal disease.

How is meningococcal disease spread?

Meningococcal disease can spread from person to person through close contact (coughing or kissing) or lengthy contact, especially among people living in the same household.

What is the best way to prevent meningococcal disease?

The single best way to prevent this disease is to be vaccinated. Meningococcal ACWY vaccines can help prevent meningococcal disease caused by serogroups A, C, W, and Y and serogroup B meningococcal (MenB) vaccines can help prevent meningococcal disease caused by serogroup B. Meningococcal ACWY Vaccines There are two kinds of meningococcal vaccines licensed by the Food and Drug Administration (FDA) for protection against serogroups A, C, W, and Y: meningococcal conjugate vaccine (MenACWY) and meningococcal polysaccharide vaccine (MPSV4). Two doses of MenACWY are routinely recommended for adolescents 11 through 18 years old: the first dose at 11 or 12 years old, with a booster dose at age 16. Serogroup B Meningococcal Vaccines Two serogroup B meningococcal vaccines—Bexsero® and Trumenba®—have been licensed by the Food and Drug Administration (FDA). For best protection, more than 1 dose of a serogroup B meningococcal vaccine is needed. The same vaccine must be used for all doses. Ask your health care provider about the number and timing of doses.

Who should receive the vaccine?

In addition to routine vaccination for adolescents, the vaccine is also recommended for certain groups of people:

People at risk because of a meningococcal disease outbreak;

Anyone whose spleen is damaged or has been removed;

Anyone with a rare immune system condition called “persistent complement component deficiency”;

Anyone taking a drug called eculizumab (Solaris®);

Microbiologists who routinely work with isolates of N. meningititis;

Anyone traveling to, or living in, a part of the world where meningococcal disease is common, such as parts of Africa;

College freshmen living in dormitories;

U.S. military recruits.

Where to obtain the meningitis vaccine:

The vaccine may be obtained from your healthcare provider or a local pharmacy. The Wellness Center does not distribute the vaccine.

Learn more about meningococcal disease: www.cdc.gov/meningococcal/
MENINGITIS RESPONSE

Please select one: *

MENINGITIS RESPONSE

Please select one: I have read and understand the Meningitis Disease Fact Sheet I have not read the Meningitis Disease Fact Sheet.
MENINGITIS RESPONSE

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I have/my child has: *

MENINGITIS RESPONSE

Please select one:

I have/my child has: Received the meningitis vaccine within the past 5 years. (The vaccine record must be attached.) Not received the vaccine, and have read, or had explained to me, the information regarding meningococcal disease. I understand the risk of not receiving the vaccine. I have decided I will not obtain immunization against meningitis disease at this time.
Please enter the date of the vaccination and attach records below: Please enter the date of the vaccination and attach records below: / MM / DD YYYY

You cannot choose a date that is more than five years ago. The date of the vaccination MUST BE within the last five years!
Please attach record of meningitis vaccine within last 5 years.

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Draw your signature into the box below. (Note: If you are under 18 a parent/guardian must sign.)

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Thank you for submitting your immunization records. A member of our staff will review and record the information within the next 3-5 business days. You may check your student Banner record to confirm receipt. There are two ways to access your information on Banner: 1.) Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "I" then choose "Immunizations." OR 2.) Log in to MySUNYOrange. In the Technical Services Tab, in Systems and Services for Students, select letter "S" then choose "Student Profile," then click on the immunizations link in the left navigation.

MENINGITIS RESPONSE FORM

MENINGITIS RESPONSE FORM

PLEASE READ THE MENINGITIS DISEASE FACT SHEET BELOW AND RESPOND. THE VACCINE IS OPTIONAL, BUT A RESPONSE IS REQUIRED.

MENINGOCOCCAL DISEASE FACT SHEET