Waiver Form For Students At Residential Schools And Colleges (Page 2 of 2) in pdf

However, please be aware that in October 2010 the Advisory Committee on Immunization Practices (ACIP) recommended

booster doses of meningococcal conjugate vaccine for healthy adolescents 16-18 years of age. Persons up to 21 years of

age entering college are recommended to have documentation of a dose of meningococcal conjugate vaccine no more than

5 years before enrollment, particularly if they are new residential students.

Is the meningococcal vaccine safe?

A vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions. Getting

meningococcal vaccine is much safer than getting the disease. Some people who get meningococcal vaccine have mild

side effects, such as redness or pain where the shot was given. These symptoms usually last for 1-2 days. A small

percentage of people who receive the vaccine develop a fever. The vaccine can be given to pregnant women. Anyone who

has ever had Guillain-Barré Syndrome should talk with their provider before getting meningococcal conjugate vaccine.

Is it mandatory for students to receive meningococcal vaccine for entry into secondary schools or colleges that

provide or license housing?

Massachusetts law (MGL Ch. 76, s.15D) requires newly enrolled full-time students attending a secondary school (those

schools with grades 9-12) or postsecondary institution (e.g., colleges) who will be living in a dormitory or other congregate

housing licensed or approved by the secondary school or institution to receive meningococcal vaccine. At affected

secondary schools, the requirements apply to all new full-time residential students, regardless of grade (including grades

pre-K through 8) and year of study. All students covered by the regulations must provide documentation of having received

a dose of meningococcal polysaccharide vaccine within the last 5 years (or a dose of meningococcal conjugate vaccine at

any time in the past), unless they qualify for one of the exemptions allowed by the law. Whenever possible, immunizations

should be obtained prior to enrollment or registration. However, students may be enrolled or registered provided that the

required immunizations are obtained within 30 days of registration.

Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the student has a

letter from a physician stating that there is a medical reason why he/she can’t receive the vaccine; 2) the student (or the

student’s parent or legal guardian, if the student is a minor) presents a statement in writing that such vaccination is against

his/her sincere religious belief; or 3) the student (or the student’s parent or legal guardian, if the student is a minor) signs

the waiver below stating that the student has received information about the dangers of meningococcal disease, reviewed

the information provided and elected to decline the vaccine.

Where can a student get vaccinated?

Students and their parents should contact their healthcare provider and make an appointment to discuss meningococcal

disease, the benefits and risks of vaccination, and the availability of this vaccine. Schools and college health services are

not required to provide you with this vaccine.

Where can I get more information?

Your healthcare provider

•

The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at (617) 983-6800

•

and

Your local health department (listed in the phone book under government)

•

Waiver for Meningococcal Vaccination Requirement

I have received and reviewed the information provided on the risks of meningococcal disease and the risks and benefits of

meningococcal vaccine. I understand that Massachusetts’ law requires newly enrolled full-time students at secondary

schools, colleges and universities who are living in a dormitory or congregate living arrangement licensed or approved by

the secondary school or postsecondary institution to receive meningococcal vaccinations, unless the students provide a

signed waiver of the vaccination or otherwise qualify for one of the exemptions specified in the law.

□

After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of

meningococcal vaccine.

Student Name: ____________________________________________ Date of Birth: _________________

Student ID or SSN: ________________________________________________________________________

Signature: __________________________________________________ Date: _________________

(Student or parent/legal guardian, if student is under 18 years of age)

Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800

MDPH Meningococcal Information and Waiver Form

Reviewed July 2014

Waiver Form For Students At Residential Schools And Colleges Page 2

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