The Kansas Department of Health and Environment recommends that all college students be immu-

nized against various vaccine preventable diseases. Coffeyville Community College requires stu-
dents 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 **Meningococcal
Influenza Tetanus, Diphtheria (TD)
Measles, Mumps, Rubella (MMR) 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 bacte-
rial 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 Date

if Student is under 18 years of age

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