THIS IS A STATE LAW. YOU MUST COMPLETE THIS FORM.
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. Please read the Meningitis Fact Sheet below.*marked fields are required. Failure to complete all required
fields will result in an invalid form.
First Name: *
MI: * Last Name: *
* Banner ID:
* Email address: * Date of Birth: * (01/01/1999)
Phone #: *
Address: * City:
* State: * Zip: *
You must check one of the boxes below *:
meningococcal meningitis immunization (Menomune™) within the past 10 years.
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 (my child) will not obtain immunization against meningococcal meningitis
disease.Please read the information below
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MENINGOCOCCAL MENINGITIS FACT SHEET
WHAT IS MENINGOCOCCAL MENINGITIS? Meningococcal disease is a severe
bacterial infection of the bloodstream or meninges (a thin lining covering the
brain and spinal cord). It is a relatively rare disease and usually occurs as a
single isolated event. Clusters of cases or outbreaks are rare in the United
HOW IS THE GERM MENINGOCOCCUS SPREAD? Meningococcal disease is
transmitted through the 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. Although anyone can come in contact
with the bacteria that causes meningococcal disease, data also indicates certain
social behaviors, such as exposure to passive and active smoking, bar patronage,
and excessive alcohol consumption, may put students at increased risk for the
disease. Patients with respiratory infections, compromised immunity, those in
close contact to a known case, and travelers to endemic areas of the world are
also at increased risk.
WHAT ARE THE SYMPTOMS? The early symptoms usually associated with
meningococcal disease include fever, severe headache, stiff neck, rash, nausea,
vomiting, and lethargy, and may resemble the flu. Because the disease progresses
rapidly, often in as little as 12 hours, students are urged to seek medical care
immediately if they experience two or more of these symptoms concurrently. The
disease is occasionally fatal.
HOW SOON DO THE SYMPTOMS APPEAR? The symptoms may appear two to 10 days
after exposure, but usually within five days.
WHAT IS THE TREATMENT FOR MENINGOCOCCAL DISEASE? Antibiotics, such as
penicillin G or ceftriaxone, can be used to treat people with meningococcal
SHOULD PEOPLE WHO HAVE BEEN IN CONTACT WITH A DIAGNOSED CASE OF
MENINGOCOCCAL MENINGITIS BE TREATED? Only people who have been in close contact
(household members, intimate contacts, health care personnel performing
mouth-to-mouth resuscitation, day care center playmates, etc.) need to be
considered for preventive treatment. Such people are usually advised to obtain a
prescription for a special antibiotic (either rifampin, ciprofloxacin or
ceftriaxone) from their physician. Casual contact as might occur in a regular
classroom, office or factory setting is not usually significant enough to cause
IS THERE A VACCINE TO PREVENT MENINGOCOCCAL MENINGITIS? Presently, there
is a vaccine that will protect against some of the strains of meningococcus. It
is recommended in outbreak situations, and for those traveling to areas of the
world where high rates of the disease are known to occur. For some college
students, such as freshman living in dormitories, there is a modestly increased
risk of meningococcal disease; students and parents should be educated about
meningococcal disease and the availability of a safe and effective vaccine.
HOW EFFECTIVE IS THE VACCINE? The meningococcal vaccine has been shown to
provide protection against the most common strains of the disease, including
serogroups A, C, Y and W-135. The vaccine has shown to be 85 to 100 percent
effective in serogroups A and C in older children and adults.
IS THE VACCINE SAFE? ARE THERE ADVERSE SIDE EFFECTS TO THE VACCINE? The
vaccine is very safe and adverse reactions are mild and infrequent, consisting
primarily of redness and pain at the site of injection lasting up to two
WHAT IS THE DURATION OF PROTECTION? The duration of the meningococcal
vaccine’s efficacy is approximately three to five years.