Meningococcal 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 online Meningococcal Vaccination Response Form below.

Note: The Advisory Committee on Immunization Practices recommends that all first-year college students up to age 21 years should have at least 1 dose of Meningococcal ACWY vaccine not more than 5 years before enrollment, preferably on or after their 16th birthday, and that young adults aged 16 through 23 years may choose to receive the Meningococcal B vaccine series. College and university students should discuss the Meningococcal B vaccine with a healthcare provider.

Important Information for review prior to filling in the Meningococcal Vaccination Response Form:

Meningococcal Vaccine Information Statement
Meningococcal Disease Fact Sheet

(Note: If you already have or are going to receive the vaccination – proof of vaccination will need to be submitted to the Registrar’s Office if you have not done so already.)

I have (for students under the age of 18: My child has):

had meningococcal immunization within the past 5 years.

I (my child) will obtain immunization against meningococcal disease within 30 days.

I (my child) will not obtain immunization against meningococcal disease.

Student First Name

Student Middle Name

Student Last Name

Last 4 digits of Student SS#

Student Birthdate

Student Personal Email Address

Student Mailing Address

Country

Street

City

Region

Postal Code

Student Phone Number:

Text me with important updates?

Yes

No

Parent Name Required for students under the age of 18.

First Name

Last Name

Electronic Signature

I have read and understand the Meningococcal Disease Fact Sheet and Vaccine Information Statement. If I (my child chose not to have the vaccine, I (my child) understand the risks of not receiving the vaccine.