MENINGITIS INFORMATION RESPONSE FORM

 

New York State Public Health Law 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:

Lauderdale Center for Student Health and Counseling
SUNY Geneseo, 1 College Circle, Geneseo, NY 14454

 

Please note that according to NYS Public Health Law, no institution shall permit any student to attend the institution in excess of 30 days without complying with this law. The 30 day period may be extended to 60 days if a student can show a good faith effort to comply.

 

Check one box and sign below.

I have:

□ had meningococcal meningitis immunization (Menomune™ or Menactra™) within the past 10 years.

    Date received: ________________________
    

□ 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 will not obtain immunization against meningococcal meningitis disease.

 

Signed                                                                                          Date

______________________________________________        ___________________

Student's name                                                                              Date of Birth
______________________________________________        ___________________

Student Social Security Number: ____________________________________________

August 2003. Source: New York State Department of Health