Proof Of Bacterial Meningitis Immunization Compliance Form printable pdf download

Proof of Bacterial Meningitis Immunization Compliance Form

The State of Texas has recently mandated that all new students submit evidence of receipt of an initial

or booster dose of a bacterial meningitis immunization in order to register for classes. Please read the

immunization requirements prior to completing this form.

PLEASE PRINT CLEARLY

SECTION I — STUDENT INFORMATION

Name_______________________________________________ Student ID #______________________________

(Last)

(First)

(Middle)

(G Number)

D.O.B._______/_______/_______ Gender: □ Male □ Female

Mobile Phone #_______________________________________ E-Mail _______________________@_________

Permanent Address ____________________________________________________________________________

City_____________________________ State_____________ Zip _____________ Country __________________

I have read and understand the Bacterial Meningitis Immunization requirements. I certify that, to the best of my

knowledge, all information on this form (including any attached documents) is true and correct. I also give my

consent for my immunization record to be entered into my student record.

Student Signature______________________________________________ Date ___________________________

________________________________________________________________________________

SECTION II — The Following Information Needs to be Completed by a Licensed Health Care Provider

(Health Care Provider Shall Complete Either 1 or 2 below)

1. I certify that ______________________________ has received the meningitis vaccine.

(Name of Student)

Vaccine Date _________________________ Vaccine Type: □ MCV4 □ MPSV4

Signature ___________________________ Title __________________________ Date ______________

Facility or Clinic Stamp (if available):

In the opinion of the physician, the bacterial meningitis vaccination required would be injurious to the health

and well-being of the student and should not be administered at this time.

Signature ___________________________ Title __________________________ Date ______________

Facility or Clinic Stamp (if available):

If Section II above is not completed by a licensed health care provider, you must attach one of the following types of documentation to this form:

An official immunization record generated from a state or local health authority, or

An official school record received from school officials, including a record from another state., or

An affidavit (submit notarized ORIGINAL only, a copy will not be accepted) signed by the student stating declination for reasons of conscience,

including religious beliefs. A conscientious exemption form from the Texas Department of State Services MUST be used and may be requested at

https://webds.dshs.state.tx.us/immco/affidavit.shtm.

Proof Of Bacterial Meningitis Immunization Compliance Form