MENINGOCOCCAL RECORDS DEADLINE: FIRST OFFICIAL DAY OF CLASSES
NAME: __________________________________________ (Please Print) Last/Family
________________________________________ First/Given
TC ID#: T________________________________________
DATE OF BIRTH ________ / ________ / ________
PART II: MENINGITITS VACCINATION RESPONSE REQUIRED FOR ALL STUDENTS. Must be completed and signed by student. Please check one box and sign below: I have: had the meningococcal meningitis immunization within the past 5 years (exact date required). The vaccine record is attached.* Month / Day / Year _______ /______ / ______ [Note: The Advisory Committee on Immunization Practices recommends that all first-year college students up to age 21 years should have at least 1 dose of Meningococcal ACWY vaccine not more than 5 years before enrollment, preferably on or after their 16th birthday, and that young adults aged 16-23 years may choose to receive the Meningococcal B vaccine series. College and University students should discuss the Meningococcal B vaccine with a healthcare provider.]
read, or have had explained to me, the information regarding meningococcal disease. I will obtain immunization against meningococcal disease within 30 days from my private health care provider or from Columbia Health. read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization against meningococcal disease. *A complete vaccine record must indicate the administration of at least 1 dose of meningococcal ACWY vaccine within the past 5 calendar years (i.e., 2012 or after) or a complete 3-dose series of meningococcal B (Bexsero or Trumenba).
MANDATORY STUDENT SIGNATURE PART II: MENINGITITS VACCINATION RESPONSE: REQUIRED FOR ALL STUDENTS. _________________________________________________________________________ Date ________ / __________ / __________ Must be completed and signed by student. Student signature
PLEASE RETURN COMPLETED FORM (WITH VACCINATION RECORD) AND ATTACHMENTS TO: TEACHERS COLLEGE, COLUMBIA UNIVERSITY OFFICE OF INSURANCE AND IMMUNIZATIONS 525 WEST 120TH STREET, BOX 308 NEW YORK, NEW YORK 10027 (P): 212-678-3006 (F): 212-678-3681
VIA MAIL, myTC PORTAL, or FAX. PLEASE NOTE: WE DO NOT ACCEPT RECORDS VIA EMAIL.
IMMUNIZATION RECORDS DEADLINE: FIRST OFFICIAL DAY OF CLASSES
NEW YORK STATE REQUIREMENTS New York State Public Law 2165 requires students to provide the College with documentation of immunity to measles, mumps and rubella. Moreover, New York State Public Law 2167 requires each student to certify their decision regarding the meningococcal meningitis vaccination. These immunization requirements apply to all registered students; but are required for students taking 6 credits or more at the College. Please read the following guidelines and adhere to the procedures for compliance. MEASLES, MUMPS, & RUBELLA IMMUNIZATION REQUIREMENTS New York State Public Health Law 2165 requires all students born on or after January 1, 1957 to provide the College with documentation of immunity to measles, mumps, and rubella. Immunity can be documented by providing exact dates of immunization shots, OR by providing results of positive blood test (titers), OR in the case of measles and mumps, by providing dates of physician diagnosis of the disease. In each case, the documents must be signed, stamped, and dated by a health care provider. Students who have attended another college or university in the United States may submit a copy of those records to prove immunity by filling out the top portion of this form and attaching the copy of your immunization records from that institution. Religious and medical exemptions are available. Free MMR vaccinations are available for college/graduate students through the New York City Department of Health. Please visit the Immunization Requirements page on our website for more information: www.tc.edu/health. Students born before January 1, 1957 are not required to provide proof of MMR, but are required to complete the meningitis vaccination response as indicated below. Students should insure that their date of birth is on file with the Office of the Registrar. MENINGOCOCCAL VACCINATION RESPONSE In compliance with New York State Public Health Law (NYS PHL), we as an institution are required to distribute information about meningococcal disease and vaccination to all students meeting enrollment criteria, regardless of whether they are residing on or off campus. Teachers College, Columbia University is required to maintain a record of the following for each student: A response to receipt of meningococcal disease and vaccine information signed by the student. This includes information on the availability and cost of the meningococcal meningitis vaccine. University student who have paid the Columbia Health Fee (CHF) are entitled to receiving vaccinations at no cost. For a complete list of vaccinations and associated fees (including individuals who have not paid CHF), please visit Columbia Health’s website.
A record of meningococcal meningitis vaccine within the past 5 years and proof of vaccine record; OR An acknowledgement of meningococcal disease risks and intent to receive meningitis immunization within 30 days signed by the student; OR An Acknowledgement of meningococcal disease risks and refusal of meningococcal meningitis immunization signed by the student
ABOUT MENINGITIS: Meningitis is rare. However, its flu-like symptoms make it difficult to diagnosis. If not treated early it can lead to swelling of the fluid surrounding the spinal cord, leading to severe or permanent damage (such as hearing loss, brain damage, seizures, limb amputation, and even death). Cases among 15 to 24 year olds have doubled since 1991. The disease strikes about 3,000 Americans each year, claiming about 300 lives. Between 100 to 125 cases occur on a college campus a year, with 15 students who die from the disease. To learn more about meningitis and the vaccine, please feel free to contact the Office of Insurance and Immunizations at Teachers College, Health Services on Columbia University’s main campus and/or consult your physician. You can also find information about the disease at:
Columbia Health Services website Ask Alice! (a Columbia University health initiative) New York State Department of Health & Meningitis Fact Sheet Center for Disease Control Meningitis Vaccine Information Statement
A vaccine is available that protects against four types of bacteria that case meningitis in the United States—types A, C, Y and W-135. These types account for nearly two thirds of meningitis cases among college students. Columbia University Health Services offers the meningococcal immunization vaccine by appointment; there is no cost for students who have paid the CHF. For a complete list of vaccinations available and fees associated for individuals who have not paid the CHF, visit the Columbia Health website. Columbia Health Services is located on the 3rd and 4th floors of John Jay Hall on Columbia University’s main campus. To make an appointment, please call (212) 854-7426. Questions? Please email
[email protected].