IMMUNIZATION REQUIREMENT FORM

ALL STUDENTS ENROLLED FOR 6 OR MORE CREDITS MUST COMPLETE THIS FORM.
Students will not be allowed to register or attend classes unless they submit this completed form. If any portion of this
document is illegible, it will not be processed. Please submit copies of all supporting documentation and keep originals
for your records. Supporting documentation does not preclude the completion of this form. Please print all information.

PART ONE: STUDENT INFORMATION

First semester at St. Francis College: FALL SPRING SUMMER YEAR
Student ID #:
Sada
Sunom Chyyo 07 / 20/ 1997
LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH
sunom1997@gmail.com
( 2 3 4 ) 2 0 5 -9 5 9
SFC E-MAIL ADDRESS PHONE NUMBER

PART TWO: MENINGOCOCCAL MENINGITIS To be completed by student.

Check ONE of the boxes and sign below. I have (for students under the age of 18: My child has):
had the meningococcal meningitis immunization within the past 5 years. The vaccine record is attached.
[Note: The Advisory Committee on Immunization Practices recommends that all first-year college students up to age 21 years should have at least 1 dose of
Meningococcal ACWY vaccine not more than 5 years before enrollment, preferable on or after their 16th birthday, and that young adults age 16 through 23 years
may choose to receive the Meningococcal B vaccine series. College and university students should discuss the Meningococcal B vaccine with a healthcare provider.]
read, or have had explained to me, the information regarding meningococcal disease. I (my child) will obtain
immunization against meningococcal disease within 30 days from my private health care provider or [ENTER NAME OF
OTHER HEALTH FACILITY]:
read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not
receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal disease.

SIGNED (student Signature or Parent/Guardian if student is a minor) DATE

PART THREE: MEASLES, MUMPS, RUBELLA To be completed by a health care provider.

NOTE: If you were born BEFORE January 1, 1957, please proceed to the birth exemption section below.
MMR VACCINATION: MMR DOES #1 1 0/2 1 / 98* HISTORY OF DISEASE: This must be verified below by a
MMR DOSE #2 / / medical provider.
*Please note that the first MMR/Measles Dose must be on or after your 1st birthday. Measles / / Mumps / /
-OR- Rubella xxxxxxxxxxxxxx
Dose #1 Dose #2
Measles / / / / EXEMPTIONS:
Mumps / / xxxxxxxxxxxxxx Religious Exemption: If a student has a deeply held
Rubella / / xxxxxxxxxxxxxx aversion to receiving vaccinations for religious reasons, a
-OR- letter signed by the student stating the same is required.
ANTIBODY TITERS: Medical Exemption: Temporary Permanent
Measles / / Result Requires a letter from health care provider detailing conditions.
Mumps / / Result Birth Exemption: Proof of birth prior to January 1, 1957
Rubella / / Result must be submitted with this form.
Health Care Provider Information:
Name (print):
Signature: Date:
Phone Number: ( ) - Place Official Stamp and/or License Number HERE

For Office Use-Immunization Compliance Use Only

Received: Entered: Health Svc. Rep: Missing Info: Y N
 INSTRUCTIONS FOR IMMUNIZATION AND
MENINGITIS DOCUMENTATION FORM
Return the signed and completed Return by the following dates:
form by mail or fax to:
Fall Entry term - 1st day semester
Office of Admissions
Spring Entry Term - 1st day of semester
180 Remsen Street Summer Entry Term - 1st day of semester
Brooklyn, NY 11201
STUDENTS WILL NOT BE ALLOWED TO REGISTER FOR ADDITIONAL CLASSES
UNLESS COMPLETED FORMS HAVE BEEN SUBMITTED OR IF THEY DO RECEIVE
718.802.0453 A PERMISSION AS OUTLINED BY NYS LAW AND DO NOT COMPLY BY DEADLINES,
WILL BE RESPONSIBLE FOR ANY FINES INCURRED.

PART ONE: To be filled out completely by the student. Please make sure to provide us with your Student Identification
Number, a phone number you can be reached, and your assigned St. Francis e-mail address. Requests for any additional
information will be made via your St. Francis e-mail address or phone.

PART TWO: MENINGOCOCCAL MENINGITIS PART THREE: Measles, Mumps, Rubella (MMR)
To be filled out completely by the student. To be filled out completely by health care provider.

On July 22, 2003, Governor Pataki signed New York State Public New York State requires degree-seeking students born on or after
Health Law (NYS PHL) 2167 requiring institutions, including January 1, 1957, to provide the university with documentation of
colleges and universities, to distribute information about immunity to measles, mumps and rubella (MMR). These highly
meningococcal disease and vaccination to all students meeting contagious diseases can cause severe health problems.
the enrollment criteria, whether they live on or off campus. You must provide proof of having received 2 measles, 1 mumps,
St. Francis College is required to maintain a record of the and 1 rubella vaccination. The dates of these vaccinations must
following for each student: be indicated and the first measles vaccination must have been
• A response to receipt of meningococcal disease and vaccine received on or after your first birthday.
information signed by the student or the student’s parent or Please note that any supporting documentation must have been
guardian. This must include information on the availability either signed or stamped by a hospital or medical provider or, in
and cost of meningococcal meningitis vaccine (Menactra or the case of prior high school or university records, stamped by an
Menomune); official of that institution. An original signature or stamp must
AND EITHER appear on the documentation. Faxes will be accepted as long
as they are received directly from a health care provider, high
• A record of meningococcal meningitis immunization within school, or university/college.
the past 10 years signed by a licensed health care provider
In addition, supportive documentation must be accompanied
(required for first-year dormitory resident students): by this form. ALL SUPPORTING DOCUMENTATION MUST CLEARLY
OR SHOW THE DATES OF YOUR VACCINATIONS ON THEM.
• An acknowledgment of meningococcal disease risks and If you have had either the measles or mumps in the past, no proof
refusal of meningococcal meningitis immunization signed of vaccination will be necessary. However, we will require that
by the student or student’s parent or guardian. you indicate when you contracted the disease and it must be
verified by a health care provider or it will not be accepted.
EXCLUSION: Students not in compliance with providing
vaccination information or students with medical or Another way to prove compliance is through a Blood Antibody
religious exemptions, are required to be excluded from the Titer test that measures the level of measles, mumps, and rubella
campus, should a disease outbreak occur. antibodies in your blood. We require that all students have
a health care provider attest on this form that the titer results
show immunity. Please note that an equivocal result will not be
accepted as complaint.

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 MENINGOCOCCAL DISEASE
FACT SHEET
What is meningococcal disease?
Meningococcal disease is caused by bacteria called Neisseria meningitidis. It can lead to serious blood infections. When
the linings of the brain and spinal cord become in flamed, it is called meningitis. The disease strikes quickly and can have
serious complications, including death.
Anyone can get meningococcal disease. Some people are at higher risk. This disease occurs more often in people who are:
• Teenagers or young adults
• Infants younger than one year of age
• Living in crowded settings, such as college dormitories or military barracks
• Traveling to areas outside of the United States, such as the “meningitis belt” in Africa
• Living with a damaged spleen or no spleen
• Being treated with Soliris® or, who have complement component deficiency (an inherited immune disorder)
• Exposed during an outbreak
• Working with meningococcal bacteria in a laboratory

What are the symptoms?

Symptoms appear suddenly – usually 3 to 4 days after a person is infected. It can take up to 10 days to develop symptoms.
Symptoms may include:
• A sudden high fever
• Headache
• Stiff neck (meningitis)
• Nausea and vomiting
• Red-purple skin rash
• Weakness and feeling very ill
• Eyes sensitive to light

How is meningococcal disease spread?

It spreads from person-to-person by coughing or coming into close or lengthy contact with someone who is sick or who
carries the bacteria. Contact includes kissing, sharing drinks, or living together. Up to one in 10 people carry meningococcal
bacteria in their nose or throat without getting sick.

Is there treatment?
Early diagnosis of meningococcal disease is very important. If it is caught early, meningococcal disease can be treated with
antibiotics. But, sometimes the infection has caused too much damage for antibiotics to prevent death or serious long-
term problems. Most people need to be cared for in a hospital due to serious, life-threatening infections.

What are the complications?

Ten to 15 percent of those who get meningococcal disease die. Among survivors, as many as one in five will have permanent
disabilities. Complications include:
• Hearing loss
• Brain damage
• Kidney damage
• Limb amputations
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 MENINGOCOCCAL DISEASE
FACT SHEET
What should I do if I or someone I love is exposed?
If you are in close contact with a person with meningococcal disease, talk with your health care provider about the risk to
you and your family. They can prescribe an antibiotic to prevent the disease.

What is the best way to prevent meningococcal disease?

The single best way to prevent this disease is to be vaccinated. Vaccines are available for people 6 weeks of age and older.
Various vaccines offer protection against the five major strains of bacteria that cause meningococcal disease:
• All teenagers should receive two doses of vaccine against strains A, C, W and Y. The first dose is given at 11 to 12 years
of age, and the second dose (booster) at age 16.
• It is very important that teens receive the booster dose at age 16 in order to protect them through the years when
they are at greatest risk of meningococcal disease.
• Talk to your health care provider today if your teen has not received two doses of vaccine against meningococcal
strains A, C, W and Y.
• Teens and young adults can also be vaccinated against the “B” strain. Talk to your health care provider about whether
they recommend vaccine against the “B” strain.
Others who should receive the vaccine include:
• Infants, children and adults with certain medical conditions
• People exposed during an outbreak
• Travelers to the “meningitis belt” of sub-Saharan Africa
• Military recruits
Please speak with your health care provider if you may be at increased risk.

What are the meningococcal vaccine requirements for school attendance?

As of September 1, 2016, children entering grades 7 and 12 must be immunized against meningococcal disease strains A, C,
W and Y according to the recommendations listed above.

Is there an increased risk for meningococcal disease if I travel?

• Meningococcal disease and outbreaks occur in the United States and around the world. The disease is more common
in the “meningitis belt” of sub-Saharan Africa. The risk is highest in people who visit these countries and who have
prolonged contact with local populations during an epidemic.
• To reduce your risk of illness, wash your hands often, maintain healthy habits such as getting plenty of rest and try not
to come into contact with people who are sick.

Travel and meningococcal disease: www.nc.cdc.gov/travel/diseases/meningococcal-disease

Learn more about meningococcal disease: www.cdc.gov/meningococcal/
For more information about vaccine-preventable diseases: www.health.ny.gov/prevention/immunization/

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 MMR VACCINE WHAT YOU NEED TO KNOW
VACCINE INFORMATION STATEMENT

(Measles, Mumps and Rubella)

Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis
Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vi

1 Why get vaccinated? 2 Who should get MMR vaccine and when?

Measles, mumps, and rubella are serious diseases. Before Children should get 2 doses of MMR vaccine:
vaccines they were very common, especially among children. • First Dose: 12–15 months of age
• Second Dose: 4–6 years of age (may be given earlier, if at least
Measles 28 days after the 1st dose)
• Measles virus causes rash, cough, runny nose, eye irritation, Some infants younger than 12 months should get a dose of MMR
and fever. if they are traveling out of the country. (This dose will not count
• It can lead to ear infection, pneumonia, seizures (jerking and toward their routine series.)
staring), brain damage, and death. Some adults should also get MMR vaccine: Generally, anyone
18 years of age or older who was born after 1956 should get at
Mumps least one dose of MMR vaccine, unless they can show that they
• Mumps virus causes fever, headache, muscle pain, loss of have either been vaccinated or had all three diseases.
appetite, and swollen glands. MMR vaccine may be given at the same time as other vaccines.
• It can lead to deafness, meningitis (infection of the brain Children between 1 and 12 years of age can get a “combination”
and spinal cord covering), painful swelling of the testicles or vaccine called MMRV, which contains both MMR and varicella
ovaries, and rarely sterility. (chickenpox) vaccines. There is a separate Vaccine Information
Rubella (German Measles) Statement for MMRV.
• Rubella virus causes rash, arthritis (mostly in women), and
mild fever. 3 Some people should not get MMR vaccine or should wait.
• If a woman gets rubella while she is pregnant, she could have a • Anyone who has ever had a life-threatening allergic reaction
miscarriage or her baby could be born with serious birth defects. to the antibiotic neomycin, or any other component of MMR
vaccine, should not get the vaccine. Tell your doctor if you have
These diseases spread from person to person through the air. any severe allergies.
You can easily catch them by being around someone who is • Anyone who had a life-threatening allergic reaction to a previous
already infected. dose of MMR or MMRV vaccine should not get another dose.
Measles, mumps, and rubella (MMR) vaccine can protect • Some people who are sick at the time the shot is scheduled may
children (and adults) from all three of these diseases. be advised to wait until they recover before getting MMR vaccine.
Thanks to successful vaccination programs these diseases are • Pregnant women should not get MMR vaccine. Pregnant
much less common in the U.S. than they used to be. But if we women who need the vaccine should wait until after giving
stopped vaccinating they would return. birth. Women should avoid getting pregnant for 4 weeks after
vaccination with MMR vaccine.
• Tell your doctor if the person getting the vaccine:
- Has HIV/AIDS, or another disease that affects the immune system
- Is being treated with drugs that affect the immune system,
such as steroids
- Has any kind of cancer
- Is being treated for cancer with radiation or drugs
- Has ever had a low platelet count (a blood disorder) - Has
gotten another vaccine within the past 4 weeks - Has recently
had a transfusion or received other blood products
Any of these might be a reason to not get the vaccine, or delay
vaccination until later.

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 MMR VACCINE WHAT YOU NEED TO KNOW
VACCINE INFORMATION STATEMENT

(Measles, Mumps and Rubella)

Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis
Hojas de información sobre vacunas están disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vi

4 What are the risks from MMR vaccine? 5 What if there is a serious reaction?

A vaccine, like any medicine, is capable of causing serious What should I look for?
problems, such as severe allergic reactions. • Look for anything that concerns you, such as signs of a severe
The risk of MMR vaccine causing serious harm, or death, is allergic reaction, very high fever, or behavior changes.
extremely small.
Getting MMR vaccine is much safer than getting measles, Signs of a severe allergic reaction can include hives, swelling
mumps or rubella. of the face and throat, difficulty breathing, a fast heartbeat,
dizziness, and weakness. These would start a few minutes to
Most people who get MMR vaccine do not have any serious
a few hours after the vaccination.
problems with it.
What should I do?
Mild Problems
• Fever (up to 1 person out of 6) • If you think it is a severe allergic reaction or other emergency
• Mild rash (about 1 person out of 20) that can’t wait, call 9-1-1 or get the person to the nearest
hospital. Otherwise, call your doctor.
• Swelling of glands in the cheeks or neck
• Afterward, the reaction should be reported to the Vaccine
(about 1 person out of 75)
Adverse Event Reporting System (VAERS). Your doctor might
If these problems occur, it is usually within 6-14 days after the file this report, or you can do it yourself through the VAERS web
shot. They occur less o en after the second dose. site at www.vaers.hhs.gov, or by calling 1-800-822-7967.
Moderate Problems VAERS is only for reporting reactions. They do not give medical advice.
• Seizure (jerking or staring) caused by fever (about 1 out of
3,000 doses) 6 The National Vaccine Injury Compensation Program
• Temporary pain and stiffness in the joints, mostly in teenage
or adult women (up to 1 out of 4) The National Vaccine Injury Compensation Program (VICP) is a
• Temporary low platelet count, which can cause a bleeding federal program that was created to compensate people who
disorder (about 1 out of 30,000 doses) may have been injured by certain vaccines.
Severe problems (very rare) Persons who believe they may have been injured by a
• Serious allergic reaction (less than 1 out of a million doses) vaccine can learn about the program and about ling a claim
by calling 1-800-338-2382 or visiting the VICP website at
• Several other severe problems have been reported after a
www.hrsa.gov/vaccinecompensation.
child gets MMR vaccine, including:
- Deafness
7 How can I learn more?
- Long-term seizures, coma, or lowered consciousness -
Permanent brain damage • Ask your doctor.
These are so rare that it is hard to tell whether they are caused • Call your local or state health department.
by the vaccine. • Contact the Centers for Disease Control and Prevention (CDC):
- Call 1-800-232-4636 (1-800-CDC-INFO) or
- Visit CDC’s website at www.cdc.gov/vaccines

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