Kansas College Immunization Waiver

The Kansas Department of Health and Environment recommends that all college students be immunized against various vaccine preventable diseases. Coffeyville Community College requires students living in Residence Halls to provide written documentation of the immunizations specifically meningococcal or a signed waiver which indicates you have been informed of the recommendations and have chosen not to be immunized. Hepatitis B Influenza Measles, Mumps, Rubella (MMR)

**Meningococcal Tetanus, Diphtheria (TD) Varicella (Chicken Pox)

**Meningococcal Disease, a potentially life-threathing bacterial infection, among teenagers and young adults have more than doubled since 1991. Of the 3000 Americans who annually contract the bacterial infection, commonly referred to as meningitis, 100 to 125 are college students. Meningitis is fatal in 10 to 15 percent of the cases and causes life-long disabilities in others. According to the American College Health Association college students, particularly freshman, living in dormitories are at a higher risk than peers the same age and who are not attending college. For specific information about meningitis, contact your family physician or the websites of the Center for Disease Control and Prevention, www.cdc.gov/nip and the American College Health Association, www.acha.org.

WAIVER OF IMMUNIZATION RECORD My signature signifies that I have been informed of the recommended immunizations, specifically meningococcal, and have chosen not to be immunized.

Print or Typed name of Student

Student’s Age

Signature of Student

Date

Signature of Parent/Guardian if Student is under 18 years of age

Date

IMMUNIZATION RECORD To be completed by the Health Care Provider: has received the meningococcal vaccine on Print or Typed name of Student

. Date

Signature of Physician/Health Care Provider IMPORTANT: This form must be signed and returned by September 1, 2007 to prevent a hold on College records. Return to: Coffeyville Community College Attn: Student Housing 400 W 11th Coffeyville, KS 67337