Medical Requirements Form (Page 2 of 2) in pdf

Medical Requirements

Meningitis Response Signature and MMR Immunization Records

are required before registration

New York State Public Health Law 2167-Meningococcal Meningitis

New York State Public Health Law 2167 took effect on August 15,2003. It requires that all colleges inform

their students about meningococcal meningitis and the meningitis vaccine. It further requires you to do the

following:

Complete Part 1 of the reverse side of this form indicating that you have received information about

meningitis and the meningitis vaccine and EITHER:

Have been vaccinated against meningitis within the last 10 years (please submit date)

Have decided not to obtain the vaccination.

Meningitis is rare. However, when it strikes, its flu-like symptoms make diagnosis difficult. Symptoms can

include high fever, severe headache, stiff neck, and rash. 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 amputations, and even death.

Meningitis is spread through the air via respiratory secretions such as coughing, sneezing, kissing or sharing

personal items like utensils, cigarettes and drinking glasses. Certain college students, particularly freshman

living in dormitories or resident halls, have been found to have an increased risk for meningitis.

A vaccine is available that protects against four types of the bacteria that cause meningitis in the United States

—types A, C, Y and W-135. These types account for nearly two thirds of meningitis cases among college

students. The vaccine is safe and effective and provides immunity for approximately 3 to 5 years. Meningitis

vaccine is available at your primary care physician or visit for clinic listings. The cost is

approximately $75.00.

To learn more about meningitis and the vaccine and other immunizations for college students, please feel free to

contact our health center and/or consult your physician. You can also find information about the disease at

NEW

YORK STATE DEPARTMENT OF HEALTH WEBSITE: , WEBSITE , THE CENTER FOR DISEASE CONTROL AND

PREVENTION (CDC): , OR AMERICAN COLLEGE ASSOCIATION (ACHA) WEBSITE:

New York State Public Health Law 2165-Measles, Mumps, Rubella

If you were born after December 31, 1956, you are required by state law to prove you are immune to Measles,

Mumps, and Rubella in order to attend college. Acceptable proof of immunity includes: immunization cards

from childhood, immunization records from High School or other schools you attended, or records from your

doctor or clinic. If you do not have proof of immunizations, you must be immunized again or have a blood test

(MMR titer) to show you are immune to all three diseases.

MMR vaccines are available at the Lehman College Student Health Center free of charge. Blood testing is also

available but requires medical insurance or payment by the student. Medical waiver: Any student with a

medical condition that prohibits vaccination may submit a doctor’s statement on letterhead for exemption.

(Temporary medical conditions, such as pregnancy, require blood titer clearance)

* You do not need proof of vaccinations if you were born on or before December 31, 1956.

Medical Requirements Form Page 2