Meningitis Immunization Record Form printable pdf download

FULTON-MONTGOMERY COMMUNITY COLLEGE

IMMUNIZATION RECORD FORM

PART I: MENINGOCOCCAL MENINGITIS

REQUIRED OF ALL STUDENTS ENROLLING FOR 6 OR MORE CREDITS— For all students regardless of age, NYS

Public Health Law mandates that you read and sign Part I.

Please Print:

Name: ____________________________________________ Address: _______________________________________

City: _________________________________________State: ______ Zip Code: ____________Phone: _____________

Social Security Number: ____________________________________ Date of Birth: ______/_______/______

day

year

Meningitis disease is a severe bacterial infection of the bloodstream or meninges (a thin layer covering the brain and spinal cord).

It is a relatively rare disease and usually occurs as a single isolated event. Clusters of cases or outbreaks are rare in the United States. It

is transmitted through air via droplets of respiratory secretions and direct contact with an infected person. Direct contact, for these pur-

poses, is defined as oral contact with shared items such as cigarettes or drinking glasses or through intimate contact such as kissing. Al-

though anyone can come into contact with the bacteria that causes meningococcal disease, data also indicates certain social behaviors,

such as exposure to passive and active smoking, bar patronage, and excessive alcohol consumption, may put students at increased risk

for the disease. Patients with respiratory infections, compromised immunity, those in close contact to a known case, and travelers to en-

demic areas of the world are also at increased risk.

The early symptoms usually associated with meningococcal disease include fever, severe headache, stiff neck, rash, nausea,

vomiting, and lethargy, and may resemble the flu. Because the disease progresses rapidly, often in as little as 12 hours, students are

urged to seek medial care immediately if they experience two or more of these symptoms concurrently. The disease is occasionally fatal.

The symptoms may appear 2 to 10 days after exposure, but usually within 5 days. Antibiotics can be used to treat people with meningo-

coccal disease. Only people who have been in close contact (household members, intimate contacts, health care personnel performing

mouth to mouth resuscitation, day care center playmates, etc.) need to be considered for preventative treatment. Such people are usually

advised to obtain a prescription for a special antibiotic from their physician. Casual contact as might occur in a regular classroom, office or

factory setting is not usually significant enough to cause concern.

Presently, there is a vaccine that will protect against some strains of meningococcus. It is recommended in outbreak situations,

and for those traveling to areas of the world where high rates of the disease are known to occur.

The meningococcal vaccine has been shown to provide protection again the most common strains of the disease, including sero-

groups A, C, Y and W-135. The vaccine has shown to be 85 to 100 percent effective in serogroups A and C in older children and adults.

The vaccine is very safe and adverse reactions are mild and infrequent, consisting of redness and pain at the site of injection lasting up to

2 days. If you wish to receive the menningococcal vaccine, contact your health care provider. The cost of the vaccine varies but is usually

around $85. Montgomery County Public Health provides the vaccine. Fulton County residents under the age of 19 may qualify for the

vaccine at a reduced fee through Fulton County Public Health.

PART I: MENINGOCOCCAL MENINGITIS RESPONSE

To be completed and signed by student or parent/guardian for students under age 18.

CHECK ONE (1) BOX ONLY

I (my child) had the meningococcal meningitis immunization (Menomune

) within the last 10 years.

Date Received: _________/_______/_________

day

year

I have read the information regarding meningococcal meningitis disease and I understand the risk of not receiving the

vaccine. I will not obtain immunization against meningococcal meningitis disease at this time.

Signature:

____________________________________________ Date: ____________/_______/______________

Parent signature if under 18 years of age.

day

year

PUBL: IMMUNIZ FORM MENI 10/05

PLEASE COMPLETE PART II ON REVERSE SIDE

Meningitis Immunization Record Form

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