Meningococcal Meningitis Vaccine Requirement Form printable pdf download

For UTSA Student Health Services

The University of Texas at San Antonio

Office Use Only

Student Health Services

Date Rec’d: _________________________________

One UTSA Circle

Staff Initials: _________________________________

 Immunized

 Waiver

San Antonio, TX 78249

Requirement Completion Date:

Mail to above address or Fax to: (210) 458-4151

MENINGOCOCCAL MENINGITIS VACCINE REQUIREMENT FORM

PLEASE NOTE: STUDENTS WILL NOT BE ALLOWED TO COMPLETE THEIR REGISTRATION UNTIL THIS FORM HAS BEEN COMPLETED

AND ALL REQUIRED DOCUMENTATION HAS BEEN RECEIVED.

DO NOT SEND YOUR ENTIRE MEDICAL

HISTORY.

We should insert a line for a date somewhere at the top of the form.

Section A (REQUIRED)

TO BE COMPLETED BY ALL STUDENTS (OR PARENTAL/REPRESENTATIVE IF STUDENT IS UNDER AGE OF 18)

Date:

myUTSA ID:

Name: (Last)

(First)

(Middle)

Semester of Entry:  Summer

 Fall

 Spring

Birth date (MM/DD/YYYY) ____/_____/______

Address: ____________________________________________

Phone: _____________________________________ (cell/home/work)

____________________________________________

Email: _____________________________________________________

____________________________________________

Section B:

MENINGITIS IMMUNIZATION DOCUMENTATION (SEE PAGE 2 FOR INFORMATION):

Select applicable documentation (PLEASE DO NOT SEND ENTIRE MEDICAL HISTORY):

 I have included my official immunization record for the meningitis immunization issued by a licensed health care provider or local

health authority; OR

 A licensed health care provider, authorized by law to administer the required vaccine, has certified my immunization and has

completed the information below (additional documentation is not required).

To be completed by licensed health care professional: Vaccination Date:

Vaccination Type:  MCV4

 MPSV4

I certify the above named student has received the Bacterial Meningitis Immunization on the date listed above.

Health Care

Professional’s Signature:

Printed Name:

Provider’s Agency Name & Address:

Date:

Section C:

MENINGITIS IMMUNIZATION WAIVER STATUS. PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK.

 In the opinion of a physician the vaccination required would be injurious to my health and well-being, Therefore an affidavit or

certificate signed by a physician duly registered and licensed to practice medicine in the U.S. is included with this form. The

affidavit or certificate includes the physician’s name, address, the state of licensure and license number.

 I’ve declined the vaccination for bacterial meningitis for reason of conscience, including religious belief; therefore a signed and

notarized affidavit is included with this form. Refer to the Student Health Services’ bacterial meningitis webpage under Affidavit

for instructions for completion and submission.

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

information

(including any attached copies) is true and correct.

STUDENT’S SIGNATURE (or PARENT/GUARDIAN SIGNATURE IF STUDENT IS UNDER THE AGE OF 18)

Student Signature:_____________________________________Print:________________________________ Date: _________

Revised 09/19/2013

Meningococcal Meningitis Vaccine Requirement Form

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