Reinhardt University Student Health Services (Page 6 of 6) in pdf

Reinhardt University Student Health Services Page 6

MENINGOCOCCAL MENINGITIS

In order to reside in Campus Housing you MUST complete this form and

deliver it to the Reinhardt University Health Center.

State of Georgia Regulations require that all colleges/universities provide detailed

information concerning the risks associated with Meningococcal Meningitis to all

students residing in campus housing and/or their parents (if the student is a minor).

This information must include the availability, effectiveness, and known

contraindications of current immunization vaccine. Documentation of immunization OR

a waiver stating you have received information but wish to decline this vaccine is

REQUIRED.

PLEASENOTE:

-+You may decide at any time to receive the vaccine even if it declined at this time.

-svaccinations are not mandatory; the university is providing the information in order

for you and/ or your parents to make an informed decision regarding the benefits and

risks of this infection and immunization.

MENINGITIS

I have been provided detailed information concerning the risks associated with

Meningitis and the availability, effectiveness, and known contra indications of

vaccination.

Statement CAt (8) or (C) must be signed:

(A)

I hereby decline the Meningitis Vaccination.

Print Name

Signature

Date

(8)

I have had the Meningitis Vaccine and will send the official document to the

Reinhardt Health Center.

Print Name

Signature

Date

(C)

I intend to receive the Meningitis Vaccine and will provide the university with

official documentation of immunization.

Print Name

Signature

Date

Reinhardt University Student Health Services Page 6