MENINGOCOCCAL MENINGITIS VACCINE REQUIREMENT FORM

WHAT YOU NEED TO KNOW ABOUT MENINGITIS

What is Meningococcal Meningitis? Meningococcal disease is a serious bacterial illness. It is a leading cause of bacterial meningitis in children 2 through 18 years old in the United States. Meningitis is an infection of the fluid surrounding the brain and spinal cord. Meningococcal disease also causes blood infections. About 1,000-2,600 people get meningococcal disease each year in the U.S. Even when they are treated with antibiotics, 10-15% of these people die. Of those who survive, another 11-19% loss their arms or legs, become deaf, have problems with their nervous systems, become mentally retarded, or suffer seizures or strokes.

Who is at risk? Anyone can get meningococcal disease. But it is most common in infants less than one year of age and people with certain medical conditions, such as lack of a spleen. College students who live on-campus and teenagers 15-19 have increased risk of getting meningococcal disease.

How is it spread? Meningococcal meningitis is spread through the air via respiratory secretions or close contact with an affected person. This can include coughing, sneezing, kissing or sharing items like utensils, cigarettes and drinking glasses.

WHAT YOU NEED TO KNOW ABOUT THE MENINGOCOCCAL MENINGITIS VACCINE.

There are two kinds of meningococcal vaccines in the United States:

Meningococcal conjugate vaccine (MCV4) and Meningococcal polysaccharide vaccine (MPSV4)

Both vaccines can prevent 4 types of meningococcal disease, including 2 of the 3 types most common in the United States and a type that causes epidemics in Africa. Meningococcal vaccines cannot prevent all types of the disease. But they do protect many people who might become sick if they didn’t get the vaccine. Both vaccines work well, and protect about 90% of people who get them.

Want more information? To find out more Meningococcal disease, the vaccines, about people who should not get the meningococcal vaccine or wait and the risks of the vaccine students should contact their doctor or nurse, call their local or state health department or Contact the Center for Disease Control Prevention (www.cdc.gov/vaccines).

TEXAS IMMUNIZATION REQUIREMENT (Senate Bill 1107) – Effective January 1, 2012. Revised October 1, 2013. http://www.legis.state.tx.us/BillLookup/Actions.aspx?LegSess=82R&Bill=SB1107

Houston Christian University complies with Texas Education Code 51.9192, “The Jaime Schanbaum and Nicolis Williams Act.” Senate Bill 1107 amends the Education Code, requiring that all first-time students attending an institution of higher education in the state of Texas, including transfer students, show evidence of vaccination against bacterial meningitis, allowing for medical or religious exemptions. Evidence of the student having received the vaccination from an appropriate health practitioner must be received by the institution of higher education at least 10 days prior to the first day of the semester or term in which the student initially enrolls. Students are exempt if 22 years of age or older by the first day of class in the initial term in which they enroll.

SECTION A : TO BE COMPLETED BY ALL ENTERING STUDENTS

Husky ID

Email

Parent/Guardian Email

First Name

Middle Name

Last Name

Student Status

U.S Citizen

Permanent Resident

International

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

SECTION B : TO BE COMPLETED BY ALL ENTERING STUDENTS

I am submitting a

meningitis immunization documentation

meningitis immunization exemption/affidavit

WHAT IS ACCEPTABLE EVIDENCE OF VACCINATION?

Listed below are the acceptable forms of evidence a student may use to submit to the institution. The documentation must be in English, state the name and other information sufficient to identify the individual who received the required vaccination, state the month, date and year the required vaccine was administered.

A. A statement provided by physician or other health care provider authorized by law to administer the Required Vaccine. The statement must include the name, address, signature or stamp, state of licensure and license number of the physician or other healthcare provider who administered the required vaccination; or of the public health official who administered the required vaccination.

B. An official immunization record generated from the state or local health authority.

C. An official record received directly from a Texas school official, or a school official in another state

Meningitis Vaccination Record

WHAT IS THE PROCESS TO REQUEST AN EXCEPTION/WAIVER?

A student (and the parent/guardian of a student under the age of 18), is not required to submit evidence of receiving the vaccination against bacterial meningitis under the following circumstances when the student submits to the institution one of the following:

A. An affidavit or certificate signed by a physician who is duly registered and licensed to practice medicine in the U.S., in which it is stated that, in the physician’s opinion, the vaccination required would be injurious to the health and well-being of the student, or

B. An Exemption for Immunizations for Reasons of Conscience form signed by the student stating that the student declines the vaccination for bacterial meningitis for reasons of conscience, including religious beliefs. The affidavit must be obtained from the Texas Department of State Health Services, https://co-request.dshs.texas.gov/.

Exemption Affidavit Document

I have received the meningitis immunization and it is current (expired after 5 years). (Signature) Note: Vaccination date must be at least 10 days prior to attending classes or housing check-in

I’ve included a statement from a physician or other health care provider authorized by law to administer the Required Vaccine.

I’ve included my official immunization record issued by a state or local health authority.

I’ve included my official record from a Texas school official or a school official in another state

I have not received the meningitis immunization.

In the opinion of a physician the vaccination required would be injurious to my health and well-being. Therefore an affidavit or certificate signed by a physician duly registered and licensed to practice medicine in the U.S. is included with this form. The affidavit or certificate includes the physician’s name, address, the state where licensed and license number.

I have declined the vaccination for bacterial meningitis for reason of conscience, including religious belief. Therefore a signed affidavit/waiver stating that I have declined for reason of conscience is included with this form. Requests for a required affidavit must be obtained from the Texas Department of State Health Services https://co-request.dshs.texas.gov/

Date Meningitis Vaccine was Administered

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