A separate, signed application must be submitted for each individual to receive
an exemption from Texas meningococcal vaccination requirements. This form is for
official use only and is not valid if photocopied. You must have a working printer
to complete this transaction.
PLEASE COMPLETE THE FOLLOWING SECTIONS:
Please complete the required fields in Sections A and B: first name, last name,
date of birth (in MM/DD/YYYY format), and zip (postal) code. Select your community
college from the drop-down menu in Section C. Use the scroll bar to the right to
read the Risks and Benefits of Meningococcal Vaccination. After reading the Risks
and Benefits, check the box certifying the information supplied is correct. After
this, the Print button at the bottom of this form
will become enabled. Clicking it will create your exemption, which you will print
and provide to your community college.
(A) Individual’s Full Name and Date of Birth:
(C) Community college/public junior college:
Risks and Benefits of Meningococcal Vaccination
||Effectiveness of Vaccine
||Possible Side Effects of Vaccination
|Meningococcal disease is an acute, potentially severe
illness that most often causes meningitis, an infection of
the spinal fluid and the fluid that surrounds the brain. It
leads to sudden onset of fever, headache, and stiff neck
and is usually accompanied by nausea, vomiting, light
sensitivity, and altered mental status. Less commonly, it
can cause pneumonia, arthritis, and ear/throat infections.
Meningococcal disease can result in hearing loss,
nervous system problems, seizures, strokes, loss of limbs
(arms, legs), and even death.
||A protective level of antibody is usually achieved
within 7 – 10 days of vaccination. The vaccines
protect about 90% of individuals who get them.
||The most common side effects are redness or pain at the
injection site lasting 1– 2 days, headache, and fatigue.
Serious allergic reactions are very rare.
I have read and I understand the Risks and Benefits of Meningococcal Vaccination
information. I understand the risks of not vaccinating self/child. I further understand
that self/child may be excluded from school attendance in times of emergency or
epidemic declared by the Commissioner of Public Health.
I do NOT want the individual named above to receive the meningococcal vaccine for
reasons of conscience, which may include a religious belief.