Health Services Forms

Required Immunization Form

To comply with New York State regulations, you must complete the following Measles, Mumps, and Rubella MMR and Meningitis Immunization Form.

Measles, Mumps, and Rubella (MMR)
New York State Public Health Law requires that full and part-time students must submit proof of immunity to Measles, Mumps, and Rubella (MMR).

Meningococcal Meningitis Vaccine
New York State Public Health Law requires all college and university students to either receive the vaccination against Meningococcal meningitis, or acknowledge that they have been made aware of the risks and have chosen not to be vaccinated.

Is there a vaccine to prevent meningococcal meningitis?
There are vaccines available which may help to prevent the five serogroups of Meningitis.

Menactra or Menveo (meningococcal conjugate vaccines) is the preferred vaccine for people ages 2-55. It helps to protect against Serogroups A, C, Y, W-135.

Bexsero or Trumenba help to protect against Serogroup B that accounts for about one-third of cases in adolescents  CDC recommends it for teens & young adults 16 through 23 years.

All College students, especially first-year students living in a dormitory are recommended  to be vaccinated with Menactra or Menveo vaccine. If they received this vaccine before their 16th birthday, they should get a booster dose before going to college. You must document that you received the Meningitis Vaccine(s) to live in our residence halls.

What is meningococcal disease?
Meningococcal disease is a severe bacterial infection of the bloodstream or meninges (a thin lining covering the brain and spinal cord). It is caused by Neisseria meningitidis also known as meningococcus.

How is the meningococcus germ spread?
The meningococcus germ is spread by direct close contact with respiratory or throat secretions of an infected person. Up to one in 10 people carry this germ in their nose or throat without any sign of illness but others may develop serious symptoms.

Who gets meningococcal disease?
Anyone can get meningococcal disease, but it is more common in infants and children, followed by a second peak in adolescence. Infants less than one year and adolescents ages 16 through 23 years have higher rates of contracting the disease than other age groups but cases occur in all age groups including the elderly. For some adolescents, such as first year college students living in residence halls there is an increased risk of meningococcal disease.

What are the symptoms?
Symptoms may include high fever, headache, stiff neck, vomiting, weakness, altered mental status (confusion), skin rash and feeling very ill. The symptoms may appear two to 10 days after exposure but usually within five days.  Among people who develop meningococcal disease, 10 to 15 percent die, in spite of treatment with antibiotics. Of those who live, permanent brain damage, hearing loss, kidney damage, loss of arms or legs, or chronic nervous system problems may occur in about 10 to 20 out of every 100 survivors.

How do I get more information about meningococcal disease and vaccination?
Contact your family health care provider or your student health service. Additional information is also available on the website of the Centers for Disease Control and Prevention (CDC).

Because of health conditions or other factors, some people should not get certain vaccines or should wait before getting them.  Review this with your health care provider.

Recommended Physical Exam Form
Please complete the front page of the  Report of Your Medical History form before you give it to the Physician or NP.