Meningococcal and Hepatitis B Vaccination Status Form HEPATITIS B AND

COLLEGE STUDENTS

Name of Student: Hepatitis B is a serious disease What can be done? Date of Birth: Hepatitis B is a virus that affects the liver. It is one There are hepatitis B vaccines available that can I, the undersigned student (if 18 years of age or older) or of several hepatitis diseases (for example, hepatitis prevent infection with the hepatitis B virus. Many parent (if student is under 18), have read and understand A and hepatitis C) that are caused by different vi- physicians offer the vaccine to patients seen in their the information provided to me about Meningococcal ruses but are similar in that they all attack the liver. offices. These are the first anti-cancer vaccines, The hepatitis B virus (HBV) can cause a short-term because they can prevent a form of liver cancer that Meningitis and Hepatitis B. I understand the benefits and (acute) illness that leads to loss of appetite, stom- can develop in a person who gets a chronic hepati- risks of being vaccinated against these diseases. The ach pain, tiredness, diarrhea, vomiting, jaundice tis B infection. information below regarding my/my child’s vaccination (yellow skin or eyes) and pain in muscles and joints. status is accurate and is being provided in compliance with These symptoms can last for several weeks. It can What about the vaccine? also cause a long-term (chronic) illness from which the Ohio Revised Code, Section 3701.133, (B). people never recover. A person might not look or A vaccine, like any medicine, is capable of causing feel sick, but he or she carries the hepatitis B virus serious problems, such as allergic reactions. Most in their blood for the rest of their lives and can infect people who get the hepatitis B vaccine do not have Meningococcal vaccine received: Yes No other people with the hepatitis B virus. Chronic any problems with it. People who have ever had a hepatitis B may cause liver damage (cirrhosis), liver life-threatening allergic reaction to baker’s yeast If yes, please list the date: / / cancer and even death. About 1.25 million people in (the kind used to make bread) or to a previous dose the United States have chronic HBV infection. Each of hepatitis B vaccine should not get the vaccine. year 80,000 more people, mostly young people, People who are moderately to severely ill at the Hepatitis B vaccine received: Yes No get infected with HBV and 4,000 to 5,000 people time the shot is scheduled should usually wait until die from chronic hepatitis B. they recover before getting the vaccine. Hepatitis B If yes, please list the dates: 1st Dose: / / vaccine is very safe and the risk of it causing seri- 2nd Dose: / / How do you catch Hepatitis B? ous harm is extremely small. Hepatitis is a serious disease and getting the vaccine is safer than getting 3rd Dose: / / Hepatitis B virus is spread through contact with the disease. College students and their parents

blood or other body fluids of an infected person. should discuss the risks and benefits of vaccination Today’s Date: / / ID # You can catch the virus by having unprotected sex, with their health care providers. For more informa- by sharing drug needles or by sharing personal tion about the hepatitis vaccine, access the Vaccine Signature (Student/Parent): items like razors and toothbrushes with someone Information Sheet at the Centers for Disease Con- who is infected. Babies of chronic HBV mothers can trol and Prevention (CDC) web site become infected during birth. Children can be in- http://www.cdc.gov/nip/publications/VIS. If college fected through exposure to blood and other body students decide to be vaccinated against hepatitis Address of Student: fluids from infected children or adults. B, they (or their parents if they are younger than 18 years of age) should contact their health provider or the university/college health center where they will Who is at risk? be attending to inquire about receiving the vaccine.

Anyone who participates in any of the behaviors Adapted from CDC publications. listed above is at risk of acquiring Hepatitis B. MENINGOCOCCAL DISEASE AND eral population; however, the vaccine is safe and ef- fective and therefore can be provided to all students who want to reduce their risk for meningococcal disease. COLLEGE STUDENTS Secondary Heading

What is meningococcal disease? WhatLorem canipsum be do donelor sit toamet, decrease consectetuer risk? adipi scing elit, sed diem nonummy nibh euismod tincidunt ut lacreet dolore magna aliguam erat volutpat. Ut wisis enim ad Meningococcal disease is a serious illness caused by minimThe meningococcal veniam, consequat, vaccine vel il lcanum dopreventlore eu four feugiat types of bacteria. It is the leading cause of bacterial meningitis nullameningococcal facilisis at ve disease.ro eros et These accum includesan et iusto two odioof the in children 2-18 years of age in the United States. dignithreess mostim qu commoni blandit prae typessent in l uptatthe U.S.um. Lor Meningococcalem ipsum Meningococcal bacteria can cause meningitis dolorvaccine sit amcannotet, con preventsectetuer all adtypesipisc ingof the elit, dis sedea diemse, but it (inflammation of the lining of the brain and spinal cord) nonudoesmmy help n toibh protect euismod people tincid untwho ut might lacreet become dolore ma sickgna if or sepsis (an infection of the bloodstream). Symptoms aligtheyuam don’t era gett vo thelutpat. vaccine. Ut wisis The enim vaccine ad min imis availableveniam, Muskingum University consequat, vel illum dolore eu feugiat nulla facilisis at of meningitis include stiff neck, headache, fever, nau- through a variety of settings including physician offices vero eros et accumsan. sea, vomiting, confusion and drowsiness. Symptoms of and university/college health centers. Wellness Center sepsis include fever, shock and coma. Death from sep- Secondary Heading sis can occur within 12 hours of the beginning of the LoremWhat aboutipsum dothelor vaccine?sit amet, consectetuer adipiscing illness—meningococcal disease can be a rapid and nonummy nibh euismod tincidunt ut lacreet dolore magna 163 Stormont St. overwhelming infectious disease. For these reasons, aligA vaccine,uam era tlike volutpat. any other Ut wisis medicine, enim ad is mi capablenim veniam of caus-, meningococcal infections that occur in childcare cen- quiings serious nostrud problems,exerci tution such ullamc asorper allergic susc reactions.ipit loborti sPeo- nisl New Concord, OH 43762 ters, elementary schools, high schools and colleges utple al shouldiquip ex not ea cogetmmodo the meni conngsequat.ococcal Duis vaccine te feugifa if theycilisi. often cause panic in the community. Every year about Duihaves au evertem haddolor a inserious hendreri allergict in vulpu reactiontate. to a previous 2,600 people in the U.S. are infected with meningococ- dose of the vaccine. Some people who get the vac- cus. Ten to 15 percent of these people die, in spite of cine may develop redness or pain where the shot was treatment with antibiotics. Of those who live, another given, and a small percentage of people develop a 10 percent lose their arms or legs, become deaf, fever. These symptoms usually last for one or two have problems with their nervous systems, become days. The risk of the meningococcal vaccine causing Susan Fracker mentally retarded or suffer seizures or strokes. serious harm is extremely small. Getting the meningo- coccal vaccine is safer than getting the disease. Peo- Director of the Wellness Center How do you catch meningococcal infection? ple who are mildly ill at the time the shot is scheduled, and women who are pregnant, can still get the vac- (740) 826-8150 Usually meningococcal infection is acquired after inti- cine. Those with moderate or severe illnesses should mate contact with an infected person. Intimate contact usually wait until they recover. College students and includes kissing, sharing toothbrushes or eating uten- their parents should discuss the timing, risks and sils or frequently eating or sleeping in the same dwell- benefits of vaccination with their health care providers. Sarah Young-Dickson ing as an infected individual. For more information about the meningococcal vac- cine, access the Vaccine Information Sheet at the Nurse Who is at risk? Centers for Disease Control and Prevention (CDC) web site http://www.cdc.gov/nip/publications/VIS. If (740) 826-8150 Anyone can get meningococcal disease, but it is most college students decide to be vaccinated against men- common in infants less than one year of age and in ingococcal meningitis, they (or their parents if they are people with certain medical conditions. College fresh- younger than 18 years of age) should contact their men, particularly those who live in dormitories, have a health provider or the university/college health center slightly increased risk of getting meningococcal dis- where they will be attending to inquire about receiving ease. The risk for meningococcal disease among non- the vaccine. Although the need for revaccination has freshman college students is similar to that for the gen- not been determined, antibody levels rapidly decline in two to three years, and if indications still exist for vac-