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:____________________