MMR/Meningitis Form (PDF)

MMR/Meningitis Form
Section 1. (Must be completed)
(Submit with original signatures only-No Fax) Student ID __ __ __ __ __ __ __ __ __
Name _____________________________________________________________________
Last
First
Address __________________________________________________________
Street City State ZIP
Phone ( )______________________ Phone ( )___________________________
Email: _______________________________________ Date of Birth ____/____/____
Major: _________________________________ Starting Semester ____________
All matriculated students enrolled in six (6) or more credits must complete this form. Students will not be allowed to attend classes unless they
submit this completed form. If any portion of this document is illegible, it will not be processed. Please submit copies of all supporting
documentation; however, supporting documentation does not preclude the completion of this form. NOTE: Please maintain a complete set of your
document, UHMS will not make future copies. Signature: ________________________________________________________________
Section 2. MMR (Information to be completed by Licensed Health Care Provider)
1st Shot 2 nd Shot Disease Date Titre Date Titre Result
(P)ostive or
(N)egative
MMR ____/____/____ ____/____/____
Measles
Must be confirmed
by a health care
provider
____/____/____ ____/____/____ ____/____/____ ____/____/____
Mumps ____/____/____ ____/____/____ ____/____/____
Rubella ____/____/____ ____/____/____
Menactra/
Menomune
(not required)
Health Provider
please document
proof of shot below
____/____/____
Equivocal
not
acceptable
Actual labs
results must
be attached
Exemptions:
Credits: Proof of less than
six credits, attach copy of
schedule. (to be submitted each
semester)
Birth: Proof of birth prior to
January 1, 1957, must be
submitted with this form
Medical: Temporary[ ] or
Permanent[ ] Requires a formal
letter from your doctor
detailing condition(s) and
duration of the exemption.
Religious: Students with
prior deeply held religious
aversions may request a waiver.
APPROVED __________
DENIED __________
Section 3.
PLEASE NOTE: THIS FORM WILL NOT BE ACCEPTED IF THIS SECTION IS NOT COMPLETED IN ITS ENTIRETY
Provider Name _________________________________________
License# __________________________ State of License ______
Provider Stamp:
Provider Signature _____________________________________
Provider Phone (_____)_________________________________
Section 4. - MENINGITIS WAIVER: (Completed by student and parent/guardian if student is a minor)
[Recommended for all students residing on campus]
I have (or for students under the age of 18, my child has):
Read (must check/ initial back of this form), 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.
I have also received a copy of the DOHHS/CDC Vaccine Information Statement dated 1/28/08 ___________
Student ____________________________ ___/___/___ Parent/Guardian ________________________________ ___/___/___
Signature Date Signature (if student is a minor) Date
RETURN THIS FORM TO: University Health & Medical Services (UHMS), Phone: (718) 246-6450 Rev.6/11 (over)
175 Willoughby Street (entrance on Fleet Place)
Brooklyn, NY 11201

Section One: This section is to be filled our completely by the student. Your student identification number (SID) is required in order to process your
information; no other defining information will be accepted. The demographic information is used for filing purposes and future communications,
please print neatly. We require a local address, telephone number and an active email address. NOTE: Only three attempts will be made to inform
you of missing information before a hold is placed on your account, which may prevent registration or continued access to classes.
Section Two: MMR Requirements
Section Four: MENINGOCOCCAL MENINGITIS Requirements
(To be completed by a Licensed Health Care Provider)
N.Y.S. Public Health Law 2165 requires college students enrolled for six
or more chargeable credits to show proof of immunization against
Measles, Mumps, and Rubella. Students born prior to January 1, 1957
are exempt from this requirement.
On July 22, 2003, Governor Pataki signed New York State Public Health
Law (NYS PHL) §2167 requiring institutions, including colleges and
universities, to distribute information about meningococcal disease and
vaccination to all students meeting the enrollment criteria, whether they
live on or off campus. This law is effective as of August 15, 2003.
MMR (Combined Live Measles, Mumps, and Rubella
Immunization). The first dose no more than 4 days prior to the first
birthday. The second dose a minimum of 28 days after the first
dose.
Single Live Measles Immunization. The first dose no more than 4
days prior to the first birthday. The second dose a minimum of 28
days after the first dose. Physician statement of Measles disease
(exact date required) is acceptable.
Single Live Mumps Immunization. Dose no more than 4 days prior
to the first birthday. Physician statement of Mumps disease (exact
date required) is acceptable.
Single Live Rubella (German Measles) Immunization. Dose no
more than 4 days prior to the first birthday. Diagnosis of Rubella
(German Measles) is not acceptable as proof of immunity.
Serologic evidence of immunity (Titre, copy of actual report must
EXEMPTIONS:
be attached) is acceptable for Measles, Mumps, and Rubella.
EQUIVOCAL TITRES ARE NOT ACCEPTABLE.
If you are requesting an exemption, you must provide the requested
proof and/or complete the required form(s).
automatic.
Section Three: Physician Information
Approval is not
Please note this section, must be filled out in its’ entirety, and is only
accepted with original signatures. All the information in this section is
required. Forms missing information from this section will not be
accepted.
Provider Name – Must be clearly printed and/or provided on via their
stamp in the allocated area (stamp that cannot be read will be
returned);
License# - Must be clearly printed and/or provided via the doctor’s
stamp;
State of License – Must be provided and clearly printed in the
allocated area;
Provider Signature – No forms will be accepted without a
doctor’s signature matching the license # provided;
Provider Phone - Must be provided and clearly printed in the
allocated area;
Provider Stamp – This is the doctor’s stamp and not the facility, the
stamp should be clearly placed in the space allocated;
Colleges in New York State are required to maintain a record of the
following for each student:
1 A response to receipt of meningococcal disease and vaccine
information signed by the student or student’s parent or guardian.
This must include information on the availability and cost of
meningococcal meningitis vaccine;
AND EITHER
A record of meningococcal meningitis immunization within the past
10 years; OR
An acknowledgement of meningococcal disease risks and refusal of
meningococcal meningitis immunization signed by the student or
student’s parent or guardian.
MENINGOCOCCAL DISEASE RISKS:
Meningitis is rare. However, when it strikes, its flu-like symptoms
make diagnosis difficult. If not treated early, meningitis can lead to
swelling of the fluid surrounding the brain and spinal column as well as
severe and permanent disabilities, such as hearing loss, brain damage,
seizures, limb amputation, and even death.
Cases of meningitis among teens and young adults 15 to 24 years
of age (the age of most college students) have more than doubled since
1991. The disease strikes about 3,000 Americans each year and claims
about 300 lives. Between 100 and 125 meningitis cases occur on college
campuses and as many as 15 students will die from the disease.
In February 2005, the CDC recommended a new vaccine, known as
Menactra for use to prevent meningococcal disease in people 11-55
years of age.
The previously licensed version of this vaccine,
Menomune is still available for this age group, as well as for children 2-
10 years old and adults older than 55 years. Both vaccines are 90%
effective in preventing the 4 kinds of the meningococcus germ (types A,
C, Y, W-135) which cause about 70% of the disease in the United States.
Meningitis vaccine is NOW available FREE via University Health &
Medical Services and its partner The Brooklyn Hospital Center. It
should also be available via your private health care provider. Cost
varies along with coverage and range from $80-150.00.
You can also find information about the disease at the New York State
Department of Health Website: http://www.health.state.ny.us/ or the
American College Health Association (ACHA) Website:
WWW.ACHA.ORG.
NOTE: This Section must be filled out by a verifiable licensed provider,
preferably a MD, whose signature, stamp, and license is clearly
documented on the form,
I have read the above information and understand the risk
of not having the vaccine. I have decided not to obtain
immunization against the meningococcal meningitis disease.
__________________________________________________
Signature:
Please note that according to NYS Public Health Law, no institutions shall permit any student to attend the institution in excess of 30 days without
complying with this law. The 30-day period may be extended to 45 days for out-of-state student by completing a request for extension form.