Form Cdphe-Imm Ci-C Rc Certificate Of Immunization For College/university Students - Colorado Department Of Public Health & Environment Page 2
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1
2Information Regarding
MENINGOCOCCAL DISEASE
For all public or nonpublic postsecondary education institutions in Colorado, the state law requires that each new
student residing in student housing, as defined by the institution, or any student who the institution requires to
complete and return a standard certificate indicating immunizations received by the student as a requirement for
residing in student housing, be provided with the information below. If the student is under the age of 18 years,
the student’s parent or guardian must be provided with this information.
Meningococcal disease is a serious disease, caused by a bacteria.
Meningococcal disease is a contagious, but a largely preventable, infection of the spinal
cord fluid and the fluid that surrounds the brain. Meningococcal disease can also cause
blood infections.
About 2,600 people get meningococcal disease each year in the United States; 10 to 15 percent
of these people die, in spite of treatment with antibiotics. Of those who live, another 10 percent
lose their arms or legs, become deaf, have problems with their nervous system, become mentally
retarded, or suffer seizures or strokes.
Anyone can get meningococcal disease, but it is most common in infants less than one year of
age and in people with certain medical conditions. Scientific evidence suggests that college
students living in residence hall facilities are at a modestly increased risk of contracting
meningococcal disease.
Immunization against meningococcal disease decreases the risk of contracting the
disease. Meningococcal vaccine can prevent four types of meningococcal disease; these include
two of the three most common in the United States. Meningococcal vaccine cannot prevent all
types of the disease, but it does help to protect many people who might become sick if they do
not get the vaccine.
A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic
reactions. The risk of the meningococcal vaccine causing serious harm, or death, is extremely
small. Getting a meningococcal vaccine is much safer than getting the disease.
More information can be obtained from the Vaccine Information Statement available at
Students and their parents should discuss the risks
and benefits of vaccination with their health care providers.
To receive the immunization against meningococcal disease, students should check with their own health care
provider or their local health department (for a list of the local public health agencies in Colorado, go to
). The institution itself may offer the vaccine at special clinics held at the
beginning of the school year or may know of other nearby locations.
Each institution must require each new student who has not received a vaccination against meningococcal
disease within the last 5 years, or, if the new student is under the age of 18 years, the student’s parent or
guardian, to check a box and sign (see below) to indicate that the signor has reviewed the information on
meningococcal disease and has decided that the new student will not obtain a vaccination against
meningococcal disease.
Please check to indicate that you have reviewed the information on meningococcal disease and
have decided that the student will not obtain a vaccination against meningococcal disease.
Date: _________________________________________________________________________________________________________
Signature (student or parent/guardian, if student is under the age of 18 years): __________________________________________
Print Name of Student: __________________________________________________________________________________________
Date of Birth: __________________________________________________________________________________________________
Student ID:____________________________________________________________________________________________________
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