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Meningitis Vaccination Response Form

Maharishi University of Management requires that all students provide the following information to the University’s campus health office:

A signed confirmation of receipt of the information sheet on meningococcal disease and vaccine and that it has been read.
A record of meningococcal meningitis immunization within the past 10 years or an acknowledgement of meningococcal disease risks and refusal of the immunization signed by the student or parent/guardian.

	I have had meningococcal meningitis immunization within the past 10 years.
Date of immunization (mm/dd/yyyy): Note: If you 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.
	I have read the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain the immunization against meningococcal meningitis disease.
	I have read the information regarding meningococcal meningitis disease and vaccination. Iwould like to obtain the immunization against meningococcal disease. I understand that the vaccine will cost me at least $100 if I am 18 years of age or older; otherwise, it is free.

Contact the campus nurse at (641) 472-7000 x3411 or nurse@mum.edu for further information.

Name of Student: (Your typed name counts as your signature.)
Date Signed (mm/dd/yyyy):
Student’s Date of Birth (mm/dd/yyyy):

The content of this page was reviewed in August 2010.

The University is accredited by The Higher Learning Commission • www.ncahlc.org
Maharishi University of Management • Fairfield, Iowa 52557 • (641) 472-7000
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