Fillable University Of Missouri - Meningococcal Vaccination Policy Compliance Form printable pdf download

University of Missouri

Meningococcal Vaccination Policy Compliance Form

lease return this form and the necessary documentation to the appropriate campus address as listed below. For additional

information on the meningococcal vaccine, see the following Centers for Disease Control (CDC) website:

If you do not have web access you may contact your

campus for information.

Student Information:

First

Student number

Date of Birth

Name: Last

For students who have received the vaccine

Section 1

I have received a meningococcal vaccine after my 16th birthday. A copy of the required documentation is attached.

Printed name of student:

Date:

Signature of student:

Waivers (complete part A or B)

Section 2

To be completed by students 18 years of age or older

I am 18 years of age or older. The University of Missouri has provided me information explaining the risks of meningococcal disease and

the effectiveness and availability of the vaccine. I understand that Missouri law Section 174.335 requires all students who reside in

on-campus housing to have received the meningococcal conjugate vaccine unless a signed statement of medical or religious exemption is

on file with the institution's administration.

A student shall be exempt from the immunization requirement for one of two reasons:

1) Upon signed certification by a licensed physician, indicating that either the immunization would seriously endanger the student's health

or life or the student has documentation of the disease or laboratory evidence of immunity to the disease.

2) If the student objects in writing to the institution's administration that immunization violates his or her religious beliefs.

Please submit the exemption request documentation with this completed form.

Printed name of student:

Signature of student:

Date:

Signature of campus official:

Date:

For students under the age of 18

I am the parent or legal guardian of

. The University of Missouri has provided me information explaining the

risks of meningococcal disease and I am aware of the effectiveness and availability of the vaccine. I understand that Missouri law Section

174.335 requires all students who reside in on-campus housing to have received the meningococcal conjugate vaccine unless a signed

statement of medical or religious exemption is on file with the institution's administration.

A student shall be exempt from the immunization requirement for one of two reasons:

1) Upon signed certification by a licensed physician, indicating that either the immunization would seriously endanger the student's health

or life or the student has documentation of the disease or laboratory evidence of immunity to the disease.

2) If the student objects in writing to the institution's administration that immunization violates his or her religious beliefs.

Please submit the exemption request documentation with this completed form.

Printed name of parent/guardian:

Date:

Signature of parent/guardian:

Signature of campus official:

Date:

Return completed form to one of the following campus addresses.

Kansas City Campus

St Louis Campus

Columbia Campus

Rolla Campus

UMKC Residential Life Office

University Health Services

Student Health Center

Student Health Services

5051 Oak Street

One University Blvd.

1020 Hitt Street

910 West 10th Street

131 Millennium Student Center

Kansas City, MO 64110

Columbia, MO 65201

Rolla, MO 65409

St. Louis MO 63121-4499

Fax: (573) 884-8902

Phone: (816) 235-8840

Phone: (573) 341-4284

Fax: (314) 516-5988

Phone: (573) 882-4661

Phone: (314) 516-5671

Email: immunizations@health.missouri.edu

Email: mstshs@mst.edu

UM 55 (SEP14) 9/14/14

University Of Missouri - Meningococcal Vaccination Policy Compliance Form

Related Articles

Related forms

Related Categories