BROOME COMMUNITY COLLEGE
STUDENT MENINGOCOCCAL MENINGITIS VACCINATION REPONSE FORM

New York State Pulbic Health Law #2167 requires that all college and university students enrolled
for at least six semester hous or the equivalent per semester, or at least four semester hours per quarter,
complete and return the following form to Broome Community College Student Heatlh Service located
in the Science Building, Room 102.

Check one option and sign below:
I have (for a student under the age of eighteen: My child has):

• ___ read or have had eplained to me, the information regarding meningococcal
  meningitis disease. I (my child) will obtain immunization against
  meningococcal meningitis within 30 days from my private health care
  provider (cost varies) or Broome County Health Department at a slidng
  fee scale of $82.00 to $64.00, OR
• ___had the meningococcal meningitis immunization (Menomune) within the
  past 10 years. Date received: __________, OR
  
• ___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.

Print Name________________________________Date of Birth________
Social Security Number______________________
Legal Signature ________________________(Student/Parent or Guardian Signature Required if student is a minor)
Date______________

8/8/03
Adaptation of New York State Health Department Form
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