Menb Vaccination Declination Form printable pdf download

The New Jersey Department of Health and Rutgers University strongly recommend, with support from the

Centers for Disease Control and Prevention, that undergraduate students on the Rutgers University–New

Brunswick campus receive the serogroup B meningococcal vaccine Trumenba® (Pfizer) this summer.

About Meningococcal Disease

Meningococcal (muh-nin-jo-cok-ul) disease is a serious illness caused by a type of bacteria called Neisseria

meningitidis. The disease may result in inflammation of the lining of the brain and spinal cord (meningococcal

meningitis) and/or a serious blood infection (meningococcal septicemia). Meningococcal disease can become

deadly in 48 hours or less. Long-term complications may include brain damage, learning problems, skin scarring,

hearing loss, and loss of arms and/or legs.

For information about symptoms, visit

Help Prevent the Spread of Serogroup B Meningococcal Disease

Keeping good hygiene helps protect yourself and helps stop the spread of serogroup B meningococcal disease.

• Do not share anything that comes into contact with the mouth (water bottles, drinking glasses, smoking and

vaping materials, eating utensils, cosmetics, lip balm)

• Always cough into a sleeve or tissue

• Wash hands frequently (use an alcohol-based sanitizer if soap and water are not available)

Serogroup B Meningococcal Disease Vaccination Declination

Kindly Print

Vaccination Declination for (Student Name): ___________________________________________

Student Date of Birth: __________________________ RUID# ______________________________

I, ______________________________ have read and understand the increased risks for serogroup

B meningococcal disease (“meningitis B”) on the Rutgers University–New Brunswick campus.

Despite recommendations made by the Centers for Disease Control and Prevention, the New Jersey

Department of Health and Rutgers University, I choose not to receive the vaccine for serogroup B

meningococcal disease.

_______________________________________

______________________________________

Student Signature

Date

_______________________________________

______________________________________

Parent/Guardian Signature

Date

(if student is a minor)

Please Note: If you are declining to receive the MenB vaccination due to limited or no health insurance,

please contact vaccine@rci.rutgers.edu to discuss options.

Return Form To:

By Mail:

Rutgers University

By Email:

Attention: Immunizations

vaccine@rci.rutgers.edu

57 US Highway 1

New Brunswick, NJ 08901

For more information, visit health.rutgers.edu/meningitis

Menb Vaccination Declination Form

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