Exemption from Meningococcal Vaccination Requirements
for Reasons of Conscience

Denotes required field


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:

                

(B) Address:

           

      

(C) Community college/public junior college:    

Risks and Benefits of Meningococcal Vaccination

Vaccine-Preventable Disease Effectiveness of Vaccine Possible Side Effects of Vaccination
Meningococcal disease - most often causes meningitis, an infection of the fluid of a person’s spinal cord and the fluid that surrounds the brain. Meningitis is characterized by high fever, headache, and stiff neck. Other symptoms may include nausea, vomiting, confusion, and sleepiness. Less commonly, meningococcal disease can cause pneumonia, bloodstream infection, arthritis, and ear infection. Meningococcal disease can result in hearing loss, nervous system problems, seizures, strokes, 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. Redness or pain may occur at the injection site in up to 59% of recipients. Fever (100ºF - 103ºF) within 7 days of vaccination is reported for up to 3% of recipients. Headache and malaise are reported in up to 60% of recipients. Serious allergic reactions, within a few minutes to a few hours of the vaccination, 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.