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The University of Texas at San Antonio Student Health Services One UTSA Circle San Antonio, TX 78249 Mail to above address or Fax to: (210) 458-4151
For UTSA Student Health Services Office Use Only Date Recd: _________________________________ Staff Initials: _________________________________ Immunized Waiver Requirement Completion Date:
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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 STUDENTS of the form. Section A (REQUIRED) TO BE COMPLETED BY ALL at the top (OR PARENTAL/REPRESENTATIVE IF STUDENT IS UNDER AGE OF 18)
Date: Name: (Last) Student Status (Check one): Address: U.S. Citizen UTSA BANNER (Student) ID: (First) Permanent Resident International (Middle) Birth date (MM/DD/YYYY) ____/_____/______
______________________________________________ Phone: _________________________________________ (cell/home/work) ______________________________________________ Email: _______________________________________________________ ______________________________________________ Student or Parental/Representative Permit (for students under the age of 18) I agree to provide all required documentation and information concerning the above students vaccination with the meningococcal meningitis vaccine (or waiver status, as the case may be). By signing below, I also give my permission for Student Health Services to share such information with other university officials when deemed necessary. Printed Name: Signature: ______________ (Parent/Guardian if Student is under 18) (Parent/Guardian if Student is under 18) Relationship to Student (if applicable): ______________
Section B: MENINGITIS IMMUNIZATION DOCUMENTATION REQUIREMENTS (SEE PAGE 2 FOR INFORMATION):
I have received the meningitis immunization (Check applicable box):
I have included a statement from a licensed health care provider authorized by law to administer the required vaccine as detailed on page 2; I have included my official immunization record for the meningitis immunization issued by a state or local health authority; or I have included my official record from a Texas school official or a school official in another state. By signing below, I give my permission for Student Health Services to share this information with other university officials when deemed necessary. Printed Name: Signature: (Parent/Guardian if Student is under 18) (Parent/Guardian if Student is under 18)
Section C: MENINGITIS IMMUNIZATION WAIVER STATUS. PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK.
I have reviewed and understand the information presented on the reverse side of this form about meningococcal meningitis and the vaccine and have chosen not to submit evidence of receiving the vaccination under the following circumstance: (Check applicable box)
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 physicians name, address, the state where licensed and license number. Ive declined the vaccination for bacterial meningitis for reason of conscience, including religious belief; therefore a signed *affidavit /waiver stating that I have declined for reason of conscience is included with this form. *Request for required affidavit must be obtained from the Texas Department of State Health Services https://webds.dshs.state.tx.us/immco/affidavit.shtm. By signing below, I give my permission for Student Health Services to share this information with other university officials when deemed necessary. Printed Name: Signature: (Parent/Guardian if Student is under 18) (Parent/Guardian if Student is under 18)
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WHAT YOU NEED TO KNOW ABOUT MENINGITIS
What is Meningococcal Meningitis? Meningococcal disease is a serious bacterial illness. It is a leading cause of bacterial meningitis in children 2 through 18 years old in the United States. Meningitis is an infection of the fluid surrounding the brain and spinal cord. Meningococcal disease also causes blood infections. About 1,000-2,600 people get meningococcal disease each year in the United States. Even when they are treated with antibiotics, 10-15 % of these people die. Of those who survive, another 11-19% suffers the loss of their arms or legs, become deaf, have problems with their nervous system, sustain cognitive deficits, or suffer seizures or strokes. Who is at Risk? Anyone can get meningococcal disease. Among the most common people getting meningococcal disease, are those 16-21 years. College freshman living in dorms have an increased risk of getting meningococcal disease. How is it Spread? Meningococcal meningitis is spread through the air via respiratory secretions or close contact with an affected person. This can include coughing, sneezing, kissing or sharing items such as utensils, cigarettes and drinking glasses.
WHAT YOU NEED TO KNOW ABOUT THE MEMINGOCOCCAL MENINGITIS VACCINE
There are two kinds of meningococcal vaccine in the U.S.: Meningococcal conjugate vaccine (MCV4) and Meningococcal polysaccharide vaccines (MPSV4). Both vaccines can prevent 4 types of meningococcal disease, including 2 of the 3 types most common in the United States and a type that causes epidemics in Africa. Meningococcal vaccines cannot prevent all types of the disease. But they do protect many people who might become sick if they didnt get the vaccine. Both vaccines work well, and protect about 90% of people who get them. Want more information? To find out more Meningococcal disease, the vaccines, about people who should not get the meningococcal vaccine or wait and the risks of the vaccine students should contact their doctor or nurse, call their local or state health department or Contact the Center for Disease Control Prevention (www.cdc.gov/vaccines)
TEXAS IMMUNIZATION REQUIREMENT (SB 1107)
The University of Texas at San Antonio complies with Texas Education Code Subchapter Z, Chapter 51, Section 51.9192 and 19 TAC Part 1, Chapter 21, Subchapter T requiring all first-time students attending an institution of higher education in the state of Texas, including transfer students, to show evidence of vaccination against bacterial meningitis, allowing for medical or religious exemptions, prior to enrollment. The institution of higher education must receive from an appropriate health practitioner evidence of the student have received the initial bacterial meningitis vaccination or booster dose during the five-year period prior to but no later than 10 days prior to the first day of the first semester of the institution in which the student initially enrolls. Students are exempt if they are (a) 30 years of age and older on the first day of the semester, or (b) enrolled only in online or other distance education courses.
WHAT IS ACCEPTABLE EVIDENCE OF VACCINATION?
Listed below are the acceptable forms of evidence a student may use to submit to the institution. The documentation must be in English, state the name and other information sufficient to identify the individual who received the required vaccination, state the month, date and year the required vaccine was administered. A. A statement provided by physician or other health care provider authorized by law to administer the required vaccine. The statement must be in English and must include the name, address, signature or stamp, state of licensure and license number of the physician or other healthcare provider who administered the required vaccination; or of the public health official who administered the required vaccination. B. An official immunization record generated from the state or local health authority. C. An official record received directly from a Texas school official, or a school official in another state.
WHAT IS THE PROCESS TO REQUEST AN EXCEPTION/WAIVER?
A student (a parent or guardian of a student under the age of 18), is not required to submit evidence of receiving the vaccination against bacterial meningitis under the following circumstances where the student submits to the institution one (1) of the following: A. An affidavit or certificate signed by a physician who is duly registered and licensed to practice medicine in the U.S., in which it is stated that, in the physicians opinion, the vaccination required would be injurious to the health and well-being of the student. B. An Exemption Form Immunizations for Reasons of Conscience form signed by the student stating that the student declines the vaccination for bacterial meningitis for reasons of conscience, including religious beliefs. The affidavit must be obtained from the Texas Department of State Health Services, https://webds.dshs.state.tx.us/immco/affidavit.shtm
