Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800
MDPH Meningococcal Information and Waiver Form Updated January 2018
Is there a vaccine against meningococcal disease?
Yes, there are 2 different meningococcal vaccines. Quadrivalent meningococcal conjugate vaccine (Menactra and Menveo)
protects against 4 serotypes (A, C, W and Y) of meningococcal disease. Meningococcal serogroup B vaccine (Bexsero and
Trumenba) protects against serogroup B meningococcal disease. Meningococcal conjugate vaccine is routinely
recommended at age 11-12 years with a booster at age 16. Students receiving their first dose on or after their 16
th
birthday
do not need a booster. Individuals in certain high risk groups may need to receive 1 or more of these vaccines based on
their doctor’s recommendations. Adolescents and young adults (16-23 years of age) who are not in high risk groups may be
vaccinated with meningococcal B vaccine, preferably at 16-18 years of age, to provide short-term protection for most strains
of serogroup B meningococcal disease. Talk with your doctor about which vaccines you should receive.
Is the meningococcal vaccine safe?
Yes. Getting meningococcal vaccine is much safer than getting the disease. Some people who get meningococcal vaccine
have mild side effects, such as redness or pain where the shot was given. These symptoms usually last for 1-2 days. A
small percentage of people who receive the vaccine develop a fever. The vaccine can be given to pregnant women. A
vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions, but these are rare.
Is meningococcal vaccine mandatory for entry into secondary schools that provide housing, and colleges?
Massachusetts law (MGL Ch. 76, s.15D) and regulations (105 CMR 220.000) requires both newly enrolled full-time
students attending a secondary school (those schools with grades 9-12) who will be living in a dormitory or other
congregate housing licensed or approved by the secondary school or institution and newly enrolled full-time students 21
years of age and younger attending a postsecondary institution (e.g., colleges) to receive a dose of quadrivalent
meningococcal vaccine.
At affected secondary schools, the requirements apply to all new full-time residential students, regardless of grade
(including grades pre-K through 8) and year of study. Secondary school students must provide documentation of having
received a dose of quadrivalent meningococcal conjugate vaccine at any time in the past, unless they qualify for one of the
exemptions allowed by the law. College students 21 years of age and younger must provide documentation of having
received a dose of quadrivalent meningococcal conjugate vaccine on or after their 16
th
birthday, unless they qualify for one
of the exemptions allowed by the law. Meningococcal B vaccines are not required and do not fulfill the requirement for
receipt of meningococcal vaccine. Whenever possible, immunizations should be obtained prior to enrollment or registration.
However, students may be enrolled or registered provided that the required immunizations are obtained within 30 days of
registration.
Exemptions: Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the
student has a letter from a physician stating that there is a medical reason why he/she can’t receive the vaccine; 2) the
student (or the student’s parent or legal guardian, if the student is a minor) presents a statement in writing that such
vaccination is against his/her sincere religious belief; or 3) the student (or the student’s parent or legal guardian, if the
student is a minor) signs the waiver below stating that the student has received information about the dangers of
meningococcal disease, reviewed the information provided and elected to decline the vaccine.
Where can a student get vaccinated?
Students and their parents should contact their healthcare provider and make an appointment to discuss meningococcal
disease, the benefits and risks of vaccination, and the availability of these vaccines. Schools and college health services
are not required to provide you with this vaccine.
Where can I get more information?
• Your healthcare provider
• The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at (617) 983-6800
or www.mass.gov/dph/imm and www.mass.gov/dph/epi
• Your local health department (listed in the phone book under government)
Waiver for Meningococcal Vaccination Requirement
I have received and reviewed the information provided on the risks of meningococcal disease and the risks and benefits of
quadrivalent meningococcal vaccine. I understand that Massachusetts’ law requires newly enrolled full-time students at
secondary schools who are living in a dormitory or congregate living arrangement licensed or approved by the secondary
school, and newly enrolled full-time students at colleges and universities who are 21 years of age or younger to receive
meningococcal vaccinations, unless the students provide a signed waiver of the vaccination or otherwise qualify for one of
the exemptions specified in the law.
□ After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of
meningococcal vaccine.
Student Name: _______________________________________ Date of Birth: _________ Student ID: _______________
Signature: __________________________________________________ Date: _________________
(Student or parent/legal guardian, if student is under 18 years of age)
click to sign
signature
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