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Evidence of Vaccination Against Bacterial Meningitis

This form may be used by any new or returning student to Texas A&M Health Science Center in order to satisfy the requirement to submit evidence of a bacterial meningitis vaccination, in compliance with Texas Education Code 51.9191/51.9192 et seq. and THECB Rule 21.610 et seq. Please return this form to the TAMHSC Office of the Registrar or to the Student Affairs Office in your school/college.

SECTION A: This section should be completed by the student.

Student Last Name: ______________________          Student First Name: ________________________

UIN: (if known)__________________________          Date of Birth: mo___________/da_____/yr__________                                                                                                     

Telephone Number: _______________________         Preferred Email Address: ___________________

Intended semester of enrollment at Texas A&M Health Science Center (Select one and indicate the appropriate year):

 _____Spring,  Year:__________          _____ Summer, Year: __________          _____Fall, Year: __________

Level of study:

_____undergraduate          _____graduate          _____professional (MD, DDS, or PharmD)

Please initial the appropriate statement:

_____My health practitioner has completed and signed Section B of this form as required.

_____I have attached to this form a true and complete copy of an official immunization record evidencing I have received a bacterial meningitis vaccination dose or booster during the five (5) year period prior to the start of the semester for which I have applied. Section B below is not completed.

_____I have attached an affidavit or certificate signed by a physician who is duly registered and licensed to practice medicine that states the vaccination would be injurious to my health and well-being. Section B below is not completed.

_____I have attached a conscientious exemption form from the Texas Department of State Health Services. Section B below is not completed.

_____I choose to waive this vaccination under the exemption of 22 years of age or older.

By signing this form, I certify that the information provided is true and accurate. I acknowledge receiving information from the university about the bacterial meningitis vaccination requirement.

Student Signature: ______________________________ Date: mo___________/da_____/yr__________

Section B. This section should be completed by a licensed Health Practitioner or Designee

Last/Family Name of the Health Practitiioner who administered the vaccination: ________________________

First/Given Name of the Health Practitioner who administered the vaccination: _________________________

Date of the administration of the bacterial meningitis vaccination: mo___________/da_____/yr__________

Last/Family Name of the vaccination recipient (i.e. the student): ____________________________________

First/Given Name of the vaccination recipient (i.e. the student): ____________________________________

Date of birth of the vaccination recipient (i.e. the student): mo___________/da_____/yr__________

By signing this form, I certify that the information provided is true and accurate. Specifically, I certify the following:

  • I am a Health Practitioner authorized by law to administer an immunization or I have legal designation to complete and sign this form on behalf of a Health Practitioner authorized by law to administer an immunization.
  • The individual who administered the bacterial meningitis vaccination to the student named above is or was a Health Practitioner authorized by law to administer an immunization.
  • The bacterial meningitis vaccination was administered to the student named above by the Health Practitioner named above and on the date provided above.

Health Practitioner or Designee Signature:______________________________ Date:   mo___________/da_____/yr_______

License Number: ___________________ Organization/Facility:_________________________Phone:____________________