Kansas College Immunization Waiver
Kansas College Immunization Waiver
Kansas College Immunization Waiver
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.
IMMUNIZATION RECORD
To be completed by the 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