Meningococcal Declination Form

NORTH COUNTRY COMMUNITY COLLEGE

Meningococcal Disease Response Form

New York State Public Health Law 2167 requires that all college and university students enrolled for at least six (6) semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete and return the following form to the North Country Community College Health Records Office.

The Advisory Committee on Immunization Practices recommends that all first-year college students up to 21 years of age have at least 1 dose of Meningococcal ACWY (MenACWY) vaccine (Brand names: Menactra, Menveo) not more than 5 years before enrollment, preferably on or after the 16^th birthday.

Young adults 16 through 23 years of age may choose to receive the Meningococcal B (MenB) vaccine series (Brand names: Trumenba, Bexsero). College and university students should discuss the MenB vaccine with a healthcare provider.

Since this is NOT a required immunization, this requirement can be met by signing and dating the declination statement on the bottom of this form. Signing this webform fulfills your requirement to submit a Meningococcal Disease Declination Response Form to North Country Community College.

Student Name*Please provide the student's full name as it appears on medical records.

Date of Birth*

Street Address*Please provide the student's current street address including apartment number, if applicable.

City*

State*

Zip Code*

Please read the Meningococcal Disease Fact Sheet.

Attestation

MENINGOCOCCAL VACCINATION DECLINATION. I understand the risks of meningococcal disease and the benefits of immunization at the recommended ages. I have decided that I (my child) will not obtain immunization against meningococcal disease at this time.

I (My child) had meningococcal immunization (MenACWY and/or MenB) within the past 5 years. The vaccine record has been submitted to healthrecords@nccc.edu or faxed to 518-891-4236

I (My child) will obtain meningococcal immunization within 30 days from my private health care provider.

I hereby attest (for students under the age of 18 years refers to the parent or legal guardian) I have reviewed the information regarding meningococcal disease.

Signature Required*Enter your full name - Parent/guardian signature if student is under 18 years of age. A typed signature in this field is acceptable in lieu of a written signature.

Signature Date*Please write today's date.

Student ID NumberIf known, please enter your NCCC student ID number.

Student Phone NumberPlease provide your preferred phone number for follow up purposes.

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