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HOUSING AND RESIDENCE LIFE

Meningitis Vaccination Information and Waiver

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*Residential Students: Please read and complete

the mandatory information listed below*

Meningitis Vaccination and Disease Information Form
Revised December 2012

The mission of Student Health Services (SHS) is to assist students in maintaining their optimum level of health and wellness. SHS is here to help you have a healthy college life. Immunizations are an important aspect of maintaining good health and preventing disease. If you have not already done so, we recommend having all of your adult vaccinations updated.


The Centers for Disease Control’s (CDC) Advisory Committee on Immunization Practices (ACIP) has established guidelines for the meningitis vaccine aimed at college students living in residence halls. The American College Health Association (ACHA) supports these guidelines. In response to these efforts, the Kansas Board of Regents has mandated that “all incoming students residing in university housing be vaccinated for meningitis or sign a waiver indicating that they refuse to take the vaccine” effective with the academic year.


In an attempt to reduce the risk of this serious disease among the college population and in compliance with Kansas Board of Regents policy, Wichita State University requires that each resident of a University residence hall complete and submit a Meningitis Vaccination and Disease Information Form within fifteen (15) days of occupancy of a University residence hall. Immunizations help decrease the risk of contracting serious diseases. SHS is aware reactions can occur with vaccinations. Most reactions are minimal and the vaccine is safer for the student.


Meningitis can cause hearing loss, kidney failure, amputation of limbs and permanent brain injury. The disease can progress rapidly, causing serious problems in as little as 12 hours. Each year the disease strikes about 3,000 people in the United States. Death occurs in approximately 10 percent of cases. With the vaccine, the majority of cases in the college age population are preventable. If you have not received the vaccine yet, SHS does have the vaccine. The cost may be less expensive than most other health providers. See the SHS website at www.wichita.edu/shs for further information on meningitis and meningitis vaccinations.


The Meningitis Vaccination and Disease Information Form should be submitted with a Housing and Residence Life application/contract. Residents (students) who do not have a signed form on file with Student Health Services within 15 days of occupancy in a University residence hall will be referred to the Associate Vice President of Student Engagement and may have a hold placed on their student records. For questions, call Student Health Services at 316-978-3620 or Housing and Residence Life at 316-978-3693.

Click Here for additional meningitis information.

MENINGITIS VACCINATION STATUS

  I have already received the meningitis vaccination or plan to receive the vaccination within 15 days of moving into the residence halls and will submit documentation to prove vaccination.

Note: To complete the meningitis requirement, you must submit a copy of your immunization record with meningitis vaccination dates to Student Health within 15 days of occupancy.

Failure to submit documentation of meningitis vaccination may cause a HOLD to be placed on your account. Please COPY, FAX, OR MAIL immunization records to:

Student Health Services
1845 Fairmount
Box 92
Wichita, KS 67260-0092
Phone: 316-978-3620
Fax:  316-978-3517

OR

I have read the above information and do not wish to receive the meningitis vaccination.

I do not wish to participate

 

Type student’s name: (By typing your name you consent that this electronic signature is valid and will hold you to all terms and conditions.)

Student’s myWSU ID:

Student’s Date of Birth:

Date:


Parent Signature:(Parent’s signature required if student is under 18; by typing your name you consent that this electronic signature is valid and will hold you to all terms and conditions in this contract.)