Meningitis Information/Waiver Form



MENINGITIS INFORMATION/WAIVER FORM

On October 20, 1999, the CDC’s Advisory Committee on Immunization Practices (ACIP) voted to recommend that college students, particularly freshmen living in dormitories and residence halls, be educated about meningitis and the benefits of vaccinations. The panel based its recommendation on recent studies showing that college students, particularly freshmen living in dormitories, have a six fold increased risk for meningitis. The recommendation further states that information about the disease and vaccination is appropriate for other undergraduate students who also wish to reduce their risk for the disease. The state of Tennessee requires our institution to provide students with information concerning meningococcal disease and the available vaccine. After this information is reviewed, the student must sign a waiver form if he/she is a resident in on-campus student housing. Please review the following information carefully and sign the waiver below.

Meningitis is a rare but potentially fatal bacterial infection. The disease is expressed as either meningococcal meningitis, an inflammation of the membranes surrounding the brain and the spinal cord or meningococcemia, the presence of bacteria in the blood. Meningococcal disease is transmitted through air via droplets of respiratory secretions and direct contact with an infected person. Direct contact for these purposes is defined as oral contact with shared items such as cigarettes or drinking glasses or through intimate contact such as kissing. When it strikes, its flu-like symptoms make diagnosis difficult. If not treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal column as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation and even death.

Cases of meningitis among teens and young adults 15 to 24 years of age (the age of most college students) have more than doubled since 1991. The disease strikes about 3,000 Americans each year and claims about 300 lives. Between 100 and 125 meningitis cases occur on college campuses and as many as 15 students will die from the disease.

A vaccine is available that protects against four types of bacteria that cause meningitis in the United States --- types A, C, Y and W-135. These types account for nearly two thirds of meningitis cases among college students. The vaccine is 85% to 100% effective in preventing the previously listed types of bacteria. The vaccine is safe, with mild and infrequent side effects, such as redness and pain at the injection site. After vaccination, immunity develops within 7 to 10 days and remains effective for approximately 3 to 5 years. As with any vaccine, vaccination against meningitis may not protect 100% of all susceptible individuals. The vaccine is available at the McKenzie Center or the Health Department in Jackson, Tennessee. The fee is approximately $100.00.

Written material on meningococcal disease and the vaccine is available in Student Health Services. If you have any questions, please feel free to contact us at (731) 352-4291.

PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. IF THE STUDENT IS UNDER THE AGE OF 18, A PARENT/GUARDIAN MUST SIGN.



I am not a resident of on-campus student housing.
I am a resident of on-campus student housing and have received information on meningococcal disease and the available vaccine. The information provided allowed me to make a responsible decision concerning vaccination. I understand the risks associated with the disease and the effectiveness and availability of the vaccine.








AND IF UNDER THE AGE OF 18:





ATTENTION: If you have received or plan to receive the meningitis vaccine before arriving on campus, you do not need to complete this form (except for identification).
I have received or plan to receive the meningitis vaccine before arriving on campus. I understand that proof of vaccine will be required by Health Services