Alvin Community College
Evidence of Vaccination against Bacterial Meningitis
Purpose of Form: This form may be used by any student who is required to satisfy the requirement to submit
evidence of a bacterial meningitis vaccination in compliance with Texas Education Code 51.9191/51.9192
et seq.
and THECB Rule 21.610
et seq.
How to Submit Evidence of Vaccination: Attach official documentation in addition to this form, if
available.
In person: Alvin Community College Admissions Office, A100
Fax: 281-756-5812
Email: Record scanned and emailed to: admissions@alvincollege.edu
SECTION A. This section must be completed by the student.
Student Name: ________________________________________________________
Student ID: _________________________ Date of Birth: _______ / ______ / ______
First Semester at Alvin Community College (Select one and indicate the appropriate year):
Fall, Year: __________ Spring, Year: __________ Summer, Year: ___________
I certify that the information provided is true and accurate. I acknowledge receiving information
from the college about the bacterial meningitis vaccination requirement. The vaccination or booster
is not more than 5 years old as of the first day of the term in which I plan to enroll.
Student Signature: _____________________________________________Date ____ /____ / ____
SECTION B. This section must be completed by a licensed Health Practitioner or Designee.
Vaccine administered: MCV-4 (Menactra) MPSV-4 (Menomune or Menveo)
Name of the Health Practitioner who administered the vaccination:
_______________________________________________________________
Date of the administration of the bacterial meningitis vaccination: _______ / ______ / ______
Name of the vaccination recipient ______________________________________________
Date of birth of the vaccination recipient ______ / _______ / ________
By signing this form, I certify that the information provided is true and accurate:
I am a Health Practitioner authorized by law to administer an immunization or I have legal designation to complete and sign
this form on behalf of a Health Practitioner authorized by law to administer an immunization.
The individual who administered the bacterial meningitis vaccination to the student named above is or was a Health
Practitioner authorized by law to administer an immunization.
The bacterial meningitis vaccination was administered to the student named above by the Health Practitioner named above
and on the date provided above.
Health Practitioner or Designee Signature: ________________________________ Date _____________
License Number: ________________________________ Phone: _______________________________
2/2019
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