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Student Immunizaton Waiver

Meningitis and Hepatitis B vaccine or signed waiver are required for residential students. If you choose the waiver, you must first read the information about the diseases provided on this form.

Personal Information

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Meningitis

Meningococcal Disease Information

A severe bacterial infection that can cause meningitis, bloodstream infection, and other localized infections. Although the disease is not common in the United States, in those who get it, symptoms develop and progress rapidly even leading to death in 24-48 hours.

Symptoms: Meningitis is characterized by fever, headache, and stiff neck. Other symptoms may include nausea, vomiting, and mental status changes. Meningococcal bacteremia is a bloodstream infection characterized by sudden onset of fever and in severe cases a petechial rash (small red or purple spots on the skin) or purpuric rash (red or purple discolorations on the skin).

Complications: Meningitis can lead to loss of a limb, permanent neurologic impairment, or death. Meningococcal bacteremia can result in joint infection, pneumonia, organ system failure, shock, and death.

Transmission: Spread by direct contact with large droplet respiratory secretions (coughing, sneezing, kissing, mouth-to-mouth resuscitation). Close household contacts of persons with meningococcal disease are at greatly increased risk of infection. This disease develops and progresses rapidly.

Vaccine: There are two meningococcal vaccines available in the U.S., meningococcal polysaccharide Vaccine (MPSV4 or Menomune(r)), and meningococcal conjugate vaccine (MCV4 or Menactra(r)). Meningococcal vaccines protect against most types of meningococcal disease, although they do not prevent all cases. The vaccine is available through your local Health Department or physician.

Who needs the Vaccine: You should get either the MPSV4 vaccine or the MCV4 vaccine if: you are a college student living in a dormitory, military recruit, have a damaged spleen or your spleen has been removed, have terminal complement deficiency, a microbiologist who is routinely exposed to the causal pathogen, traveling or residing in countries in which the disease is common.

Meningitis Waiver

By selecting yes to this waiver you are stating that you have read the information provided about Meningitis and understand the potential fatal nature of the disease, the availability of the vaccine and refuse to be vaccinated.

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Hepatitis B

Hepatitis B Information

Hepatitis B is a serious disease caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. Persons at risk for HBV infection might also be at risk for infection with hepatitis C virus (HCV) or HIV.

Symptoms: About 30% of persons have no signs or symptoms. Signs and symptoms are less common in children than adults. These include: fatigue, abdominal pain, loss of appetite, jaundice, nausea, vomiting, diarrhea, joint pain

Complications: The long-term effects of Hepatitis B have serious consequences like hepatocellular carcinoma (liver cancer). Death from chronic liver disease occurs in 15%-25% of chronically infected persons.

Transmission: Occurs when blood from an infected person enters the body of a person who is not infected. HBV is spread through having sex with an infected person without using a condom (the efficacy of latex condoms in preventing infection with HBV is unknown, but their proper use might reduce transmission), by sharing drugs, needles, or "works" when injecting drugs, through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth.

Vaccine: Hepatitis B vaccine is available for all age groups to prevent hepatitis B virus infection. The vaccine is given in a three shot series. The vaccine is available through your local Health Department or physician.

Who needs the Vaccine: Persons with multiple sex partners, men who have sex with men, diagnosis of a sexually transmitted disease, injection-drug user, sex contacts of infected persons, infants born to infected mothers, household contacts of chronically infected persons, infants/children of immigrants from areas with high rates of HBV infection, health-care and public safety workers with exposure to blood.

Hepatitis B Series Waiver

By selecting yes to this waiver you are stating that you have read the information provided about Hepatitis B and understand the potential fatal nature of the disease, the availability of the vaccine and refuse to be vaccinated.

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