Farmingdale
State College
State University of New York
Farmingdale
State College
State University of New York
+
Meningococcal Vaccination
Response Form
Check one box and sign below.
I have (for students under the age of 18; My child has):
o
had meningococcal immunization within the past ve years. The vaccine record is attached.
Note: The Advisory Committee on Immunization Practices recommends that all rst-year college students up to age 21 years should have at least one dose of
Meningococcal ACWY vaccine not more than 5 years before enrollment, preferably on or after their 16th birthday, and that young adults aged 16 through 23
years may choose to receive the Meningococcal B vaccine series. College students should discuss the Meningococcal B vaccine with a health care provider.
o
read or have had explained to me, the information regarding meningococcal disease. I (my child) will obtain immunization against meningococcal disease
within 30 days from my private health care provider or Farmingdale State College Health and Wellness Center.
o
read or have had explained to me, the information regarding meningococcal disease. I understand the risks of not receiving the vaccine. I have decided
that I (my child) will not obtain immunization against meningococcal disease.
__________________________________________________________________________________________ Date __________/__________/__________
Signed
(
Student MUST sign, if under 18, parent or guardian must sign
)
___________________________________________________________________________ Students Date of Birth __________/__________/_________
Print Student’s Name
Student’s E-mail Address _______________________________________________________ Student RAM ID#_______________________________
Student’s Mailing Address ______________________________________________________________________________________________________
Return this for to:
HEALTH & WELLNESS CENTER
______________________________________________________________________________________________________
FARMINGDALE STATE COLLEGE
2350 BROADHOLLOW ROAD
FARMINGDALE, NY 11735
Student’s Phone Number ( _________ ) ______________________________________________
About Meningococcal Disease
What is meningococcal disease?
Meningococcal disease is caused by bacteria called Neisseria meningitis. It can
lead to serious blood infections. When the linings of the brain and spinal cord
become inamed, it is called meningitis. The disease strikes quickly and can
have serious complications, including death.
Anyone can get meningococcal disease. Some people are at higher risk. This
disease occurs more often in people who are:
n
Teenagers or young adults.
n
Infants younger than one year of age.
n
Living in crowded settings, such as college dormitories or military barracks
n
Traveling to areas outside of the United States, such as the “Meningitis
belt” in Africa.
n
Living with a damaged spleen or no spleen.
n
Being treated with Soliris
®,
or who have complement component deciency
(an inherited immune disorder).
n
Exposed during an outbreak.
n
Working with meningococcal bacteria in a laboratory.
What are the symptoms?
Symptoms appear suddenly - usually three to four days after a person is infected.
It can take up to 10 days to develop symptoms. Symptoms may include:
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A sudden high fever
n
Headache
n
Stiff neck (meningitis)
n
Nausea and vomiting
n
Red-purple skin rash
n
Weakness and feeling very ill
n
Eyes sensitive to light
How is meningococcal disease spread?
It spreads from person-to-person by coughing or coming into close or
lengthy contact with someone who is sick or who carries the bacteria.
Contact includes kissing, sharing drinks, or living together. Up to one
in 10 people carry meningococcal bacteria in their nose or throat without
getting sick.
Is there treatment?
Early diagnosis of meningococcal disease is very important. If it is caught
early, meningococcal disease can be treated with antibiotics. But, sometimes
the infection has caused too much damage for antibiotics to prevent death or
serious long-term problems. Most people need to be cared for in a hospital
due to serious, life-threatening infections.
What are the complications?
Ten to 15 percent of those who get meningococcal disease die. Among
survivors, as many as one in ve will have permanent disabilities.
Complications include:
n
Hearing loss
n
Brain damage
n
Kidney damage
n
Limb amputations
Health + Wellness Center
( 934-420-2009
934-420-2137
+ wellness@farmingdale.edu
190947
