Mandatory Immunization Form - Ave Maria University
ADVERTISEMENT
1
2Please fill out and return to:
N
S
:
A
M
U
- D
S
A
AME OF
TUDENT
VE
ARIA
NIVERSITY
IVISION OF
TUDENT
FFAIRS
5050 Ave Maria Blvd., Ave Maria FL 34142
Phone: 239.280.2540 - Fax: 239.304-7034
MANDATORY IMMUNIZATION FORM
In 2003, the Florida Legislature passed Florida Statute 1006.69 mandating vaccination against Meningococcal
Meningitis and Hepatitis B for every student residing in on-campus housing at any postsecondary educational
institution or receipt of a signed waiver declining receipt of these vaccinations, after being made aware of the risks
associated with the diseases. All Ave Maria University residential students must satisfy immunization requirements
in order to reside on campus. Housing applications will not be processed until proof of immunization, immunity, or
exemption is satisfied. Your health care provider must complete and sign this form. Dates must include month, day,
and year (mm/dd/yy). Please do not send originals.
Immunization Requirements
If you were born after January 1, 1958, proof of TWO doses of measles (rubeola) and ONE dose of rubella (German measles) is required.
Measles (Rubeola): MANDATORY (you must show proof of ONE of the below requirements.)
Dose #1:
Blood Test:
OR
Dose #2:
Blood test showing the presence of measles
antibody—a written, dated statement signed by a
Immunization with TWO doses of measles vaccine—
physician on his/her stationery stating the date you
the first given on or after the first birthday, the second
had the disease.
given at least 30 days after the first, AND BOTH in
1958 or later.
Rubella (German Measles): MANDATORY (you must show proof of ONE of the below requirements.)
N.B. Having had the rubella disease is NOT acceptable proof.
Dose #1:
Dose #1:
Dose #2:
OR
One dose of rubella vaccine on or after the first
Immunization with TWO doses of measles vaccine—
birthday in 1969 or later; blood test showing the
the first given on or after the first birthday, the second
presence of the rubella antibody.
given at least 30 days after the first, AND BOTH in
1958 or later.
Meningitis: MANDATORY (you must show proof below.)
N.B. Meningitis is an infection of the fluid of the spinal cord and brain caused by a virus or bacteria and usually spread through
exchange of respiratory and throat secretions (e.g., coughing, kissing). Bacterial meningitis can be quite severe and may result in
brain damage, hearing loss, or learning disability. A vaccine is currently available that effectively provides immunity for most
types of bacterial meningitis, the more serious form, but there is no vaccine for the viral type.
REQUIRED FOR RESIDENTIAL STUDENTS: Meningococcal (Menactra, Menveo, Menomune, MPSV4, MCV4) Booster dose
must be given to residential students if the previous dose was given before the age of 16. If initial dose given age ≥16 yrs,
no booster dose is required.
I have received the meningitis vaccine.
Meningococcal #1 ____/____/____
Booster Meningococcal ____/____/____
Office stamp to include name of physician and/or medical facility where vaccine provided:
Signature of health care provider: _____________________________________________
Date: _____________
Fall 2016
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical