MENINGOCOCCAL MENINGITIS ELECTRONIC VACCINATION RESPONSE FORM

Mercy College is required to maintain a record of the following for each student:

1. A response to receipt of meningococcal disease and vaccine information signed by the student.
2. A record of meningococcal meningitis immunization within the past 10 years; or
3. An acknowledgement of meningococcal disease risks and refusal of the immunization signed by the student.

* Indicates the required items

New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester hours complete and return the following form to the Registrar's Office. Please check one:

I have (for students under the age of 18: My child has):

had meningococcal meningitis immunization within the past 10 years.

If checked, date received:   (Date Format: MM/YYYY)

[Note: If you (your child) received the meningococcal vaccine available before February 2005 called Menomune�, please note this vaccine's protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate vaccine called Menactra� should be considered within 3-5 years after receiving Menomune�.]

read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease.

*Student's Name

*Student's Date of Birth

 (Format: MM/DD/YYYY)

*Student's Mercy College ID or SSN:

ELECTRONIC SUBMISSION OF THIS FORM THROUGH MERCY CONNECT WILL BE ACCEPTED AS YOUR SIGNATURE.

OR YOU CAN FAX THIS FORM TO 914-674-7516.

Click here to download the print version of the form

CLICK HERE FOR MENONGOCOCCAL INFORMATION