MEDICAL REQUIREMENTS (intra-CUNY-Transfer students should already have records in CUNY First) Completion of the Meningitis Response Section (Part 1) and MMR Immunization Records (Part 2) are required before registration. Name: ___________________________________________ EMPLID#:__________________________ Complete Address: __________________________________________________________________________ Phone: (____) ________________________ DOB: ______________________ Email:_________________________________ Part 1- TO BE COMPLETED AND SIGNED BY THE STUDENT (OR PARENT/GUARDIAN FOR STUDENT UNDER THE AGE OF 18) MENINGOCOCCAL MENINGITIS. CHECK ONE (1) BOX ONLY . I have read, (see reverse side) or have had explained to me, the information regarding meningococcal meningitis. I have been vaccinated within 5 years. The vaccine record is attached. OR . I have read, (see reverse side) or have had explained to me, the information regarding meningococcal meningitis. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis. Meningitis Vaccine is not available at the health center. Signed: _______________________________________ Date:______________________ Part 2 - SUBMIT PROOF OF IMMUNIZATIONS (immunization card copy, high school/college records, City- or State-wide Immunization Registry copy, doctor/clinic record, or lab report proving immunity to MMR) OR HAVE YOUR HEALTH CARE PROVIDER COMPLETE, SIGN, AND STAMP BELOW. M.M.R. (Measles, Mumps, Rubella) (Two doses given after 1/1/1973) 1. Dose 1 given at age 12 months or later……………………………… Date: ____/____/____ 2. Second dose given 28 days later & after 15 months of age… …….. Date: ____/____/____ OR 3. Copy of Laboratory Report proving immunity must be submitted. (MMR Titer) I certify that the above-named student has received the above immunizations, or I have enclosed laboratory results indicating immunity. Physician signature AND stamp required _________________________________________________ Address: ___________________________________________________________________________ Date: ___/___/____ Phone#: (____) ______________ Stamp:_______________________________ Please submit form via Student Health Center web site: http://www.lehman.edu/student-health-center/immunization-requirements.php Medical Requirements Meningitis Response Signature and MMR Immunization Records are required before registration New York State Public Health Law 2167-Meningococcal Meningitis New York State Public Health Law 2167 took effect on August 15, 2003. It requires that all colleges inform their students about meningococcal meningitis and the meningitis vaccine. It further requires you to do the following: Complete Part 1 on the reverse side of this form indicating that you have received information about meningitis and the meningitis vaccine and EITHER: Have been vaccinated against meningitis within the last 5 years (must supply documentation). OR Have decided not to obtain the vaccination. Meningitis is rare. However, when it strikes, its flu-like symptoms make diagnosis difficult. Symptoms can include high fever, severe headache, stiff neck, and rash. If not treated early, meningitis can lead to swelling of the fluid surrounding the brain and spinal column as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputations, and even death. Meningitis is spread through the air via respiratory secretions such as coughing, sneezing, kissing or sharing personal items like utensils, cigarettes and drinking glasses. Certain college students, particularly freshman living in dormitories or resident halls, have been found to have an increased risk for meningitis. A vaccine is available that protects against four types of the bacteria that cause meningitis in the United States —types A, C, Y and W-135. These types account for nearly two thirds of meningitis cases among college students. The vaccine, Menactra, is safe and effective and provides immunity for approximately 5 years. Meningitis vaccine is available at your primary care physician or visit www.istm.org for clinic listings. To learn more about meningitis and the vaccine and other immunizations for college students, please consult with your physician, www.health.state.ny.us, www.cdc.gov/ncidod/dbmd/diseaseinfo, or www.acha.org New York State Public Health Law 2165-Measles, Mumps, Rubella If you were born after December 31, 1956 and plan to take 6 or more credits, you are required by state law to prove you are immune to Measles, Mumps, and Rubella in order to attend college. Acceptable proof of immunity includes: your immunization card from childhood, immunization records from high school or colleges you attended, a print-out from the City- or State-wide Immunization Registry, or records from your doctor or clinic. If you do not have proof of immunizations, you must be re-immunized or have a blood test (MMR titer) to show your immunity to all three diseases (your lab report is required). MMR vaccines are available at the Lehman College Student Health Center free of charge. Blood testing is also available but requires medical insurance. Medical waiver: Any student with a medical condition that prohibits vaccination may submit a doctor’s statement on letterhead for exemption. (Temporary medical conditions, such as pregnancy, require blood titer clearance) Religious exemption: Any student whose religious belief prohibits vaccination must complete the CUNY Religious Exemption form. Exempted students will not be permitted on campus during a communicable disease outbreak. * You do not need proof of vaccinations if you were born on or before December 31, 1956. However, you must complete Part 1 of the Medical Requirements form concerning meningitis.