MENINGOCOCCAL MENINGITIS VACCINATION

RESPONSE FORM 

Dear Echo Lake Staff:

Under New York State law, Camp Echo Lake is required to provide you with information about meningococcal disease, commonly known as meningitis, and the vaccine, and maintain a record of the following for each camper:

  • A signed notice that you have received information about meningococcal meningitis disease and vaccine information; AND EITHER
  • A record of meningococcal meningitis immunization within the past 10 years; OR
  • An acknowledgement of meningococcal meningitis disease risks and a waiver of meningococcal meningitis immunization signed by the staff person being employed. 

Bacterial meningitis is rare. However, its flu‑like symptoms can make diagnosis difficult and can lead to a delay in treatment. If not treated early, meningitis can lead to severe inflammation around the brain and spinal column as well as severe and permanent disabilities, including hearing loss, brain damage, seizures, limb amputation, shock and even death.

Many adolescents do receive the meningococcal vaccine prior to starting college when they will be living in dormitory settings. Because the vaccine does not offer permanent protection, and it is not certain that re-vaccination is effective, the decision to vaccinate younger children especially should be carefully considered and discussed with your physician.  According to the manufacturer, protection lasts “for at least two years and possibly longer”.

For more information regarding meningococcal meningitis vaccine and disease, please consult your child’s physician.  You can also visit www.meningitisvaccine.com, WWW.CDC.GOV/NCIDOD/DBMD/DISEASEINFO and WWW.HEALTH.STATE.NY.US

Sincerely,

Tony Stein                     Sam Weinstein, MD
Director                         Camp Medical Director

New York State Public Health Law requires the operator of an overnight children’s camp to maintain a completed response form for every camper or staff who attends camp for seven (7) or more nights.   

 Your Email Address:        

Click one circle and initial below.   

I have had the meningococcal meningitis immunization (Menomune™/Menactra™) within the past 10 years.

Date received:

 [Note:  The vaccine’s protection lasts for approximately 3 to 5 years.  Revaccination may be considered within 3-5 years.]

I have read, or have had explained to me, the information regarding meningococcal meningitis disease.  I understand the risks of not receiving the vaccine.  I have decided that I will not obtain immunization against meningococcal meningitis disease.

Sign (your initials)   

Your Name:

Date of Birth:

               


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