E Cedarville University Student Health Form (Page 5 of 6) in pdf

Student Health Form (Page 5 of 6)

AttentIon: StUDentS DeSIrIng reSIDence hALL hoUSIng At ceDArVILLe UnIVerSIty

Students 18 years and older may complete this form online at cedarville.edu/vaccinationform.

q I completed this form online. (If checked, you may leave this page blank.)

q I completed this form and turned it in to Residence Life.

Student’s Name ________________________________________________

Date of Birth __________________________________________________________

SectIon 9: (reQUIreD) MenIngococcAL AnD hepAtItIS B VAccInAtIon StAtUS forM

The state of ohio requires all institutions of higher education to have a disclosure of vaccination status on file for meningitis and hepatitis B. The law does not require students to be vaccinated but does require universities and

colleges to keep a Meningococcal and Hepatitis B Vaccination Status Form on file for each student living in the residence halls. The intent of the law is to educate young adults on the risks of meningococcal disease and hepatitis

B and to encourage prevention by vaccination.

Meningococcal (Bacterial) Meningitis

Meningococcal (bacterial) meningitis is a potentially fatal bacterial infection that causes inflammation of the membranes surrounding the brain. Symptoms of bacterial meningitis in order of frequency are: stiff neck, fever,

headache, rash, extreme fatigue, nausea, vomiting, and sensitivity to light. The disease is transmitted through close, direct contact with the oral secretions of an infected person by sharing glasses or utensils, kissing, and

coughing. Meningitis is rare in persons over 30 years old and is more common in the late winter and early spring.

In 2005, a new vaccine was released for bacterial meningitis called Menactra, a conjugate vaccine that may produce lifetime immunity and is now the preferred vaccine to prevent bacterial meningitis. For more

information on Menactra, visit .

hepatitis B

Hepatitis B is a viral infection of the liver that is transmitted from the blood and body fluids of an infected person through another person’s mucous membranes or broken skin, much like AIDS (HIV) is transmitted.

Hepatitis B is a vaccine-preventable disease. The vaccination schedule consists of three injections: the initial immunization, the second injection one month from the first injection, and the third injection five months from

the second injection for optimum immunity. In the event of disruption of the schedule, the immunizations can still be continued, but a blood titer is recommended to determine if a fourth shot is needed.

If yoU Are pLAnnIng to reSIDe In the reSIDence hALLS, yoU MUSt coMpLete the MenIngococcAL AnD hepAtItIS B VAccInAtIon StAtUS forM BeLoW.

yoU Are not reQUIreD to hAVe the VAccInAtIon, BUt yoU MUSt DIScLoSe yoUr VAccInAtIon StAtUS. If you want to get the vaccinations or have questions about whether you should

be vaccinated, talk with your family doctor or call University Medical Services at 937-766-7863. For more information about the new law, meningitis, and hepatitis B, visit

I, the undersigned student (if 18 years of age or older) or parent (if student is under 18), have read and understand the information provided to me about meningococcal meningitis and hepatitis B.

I understand the benefits and risks of being vaccinated against these diseases. The information below regarding my/my student’s vaccination status is accurate and is being provided in compliance with the ohio Revised

Code, Section 1713.55, (B).

Meningococcal Vaccine received

q Yes

q No

q Yes, but not sure of date.

If yes, please list the date.

________________________________________________

Hepatitis B Vaccine received

q Yes

q No

q Yes, but not sure of dates.

If yes, please list the dates.

First Dose __________________________________________

Second Dose ________________________________________

Third Dose __________________________________________

As required by the HIPAA privacy rule, UMS may not use or disclose your protected health information except as provided in the UMS Notice of Privacy Practices (cedarville.edu/privacypractices) without your

authorization. I hereby authorize UMS and any of its employees to use or disclose my patient health information to the following person(s), entity(s), or business associates of UMS: Cedarville university student Life division.

Patient health information authorized to be disclosed: information related to my meningococcal and hepatitis B vaccination status for the purpose of staying in the residence hall. For the specific purpose of:

Compliance with Ohio revised Code, section 1713.55, (B).

________________________________________________________________________________________________________________________________

Signature of Student

Date

________________________________________________________________________________________________________________________________

Signature of Parent or Guardian (if student is under age 18)

Date

University Medical Services • 251 N. Main St. • Cedarville, OH 45314 • 937-766-7862 • fax: 937-766-7865 • ums@cedarville.edu • cedarville.edu/ums