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 16 th 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

_________________________________________________________________________ Student signature

Date ________ / __________ / __________

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.