Health Services
227 West 27
th
Street, Room A402
New York City 10001-5992
P 212 217.4190 F 212 217.4191
Forms/MeningitsInfoResponseForm20150429.docx Updated 4/29/15
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 to FIT Health Services.
Please note that according to NYS Public Health Law, no institution shall permit any student to attend the institution in excess of 30 days
without complying with this law. The 30 day period may be extended to 60 days if a student can show a good faith effort to comply.
Check one box and sign below:
I have / My child has (for students under the age of 18):
Had the meningococcal meningitis immunization (Menomune™) within the last 5 years.
Immunization date: ____________________________
(Note: If you (your child) received the meningococcal vaccine available before February 2005 called Menomune
, please note this
vaccine’s protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate vaccine called Menactra
should be
considered within 3-5 years after receiving Menomune
.)
Read, or 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.
Student’s Signature:
(If student is a minor, parent/guardian must sign) Date:
Print Student’s name: Student’s Date of Birth:
Student’s Email address: Student ID#:
Student’s Mailing address:
To avoid jeopardizing enrollment, complete this form and return it to Health Services promptly.
To submit, scan and upload to the FIT Health Portal at fit.studenthealthportal.com.
If you have any questions, call Health Services at 212 217.4190.
