Texas Minimum State Vaccine Requirements for College Entry

MENINGITIS IMMUNIZATION REQUIREMENT (quadrivalent MenACWY-CRM meningococcal vaccine)

The State of Texas requires all students under the age of 22 to provide an official immunization record verifying that the student has a current (received within the last five years) vaccination against bacterial meningitis or the appropriate State Waiver or medical waiver.

Complete this section if submitting proof of current vaccination

Complete this section if submitting an exemption

The Bacterial Meningitis (quadrivalent MenACWY-CRM meningococcal) vaccine is the required vaccination for enrollment purposes. Please submit a copy of your vaccination record showing proof of the vaccine. The record must include your name, birthdate, physician signature, vaccination type and date of vaccination. Be sure to put your OLLU student ID # on all documentation.

The Meningitis B vaccine does not meet the requirement set forth by the State of Texas for enrollment purposes.

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Complete this section if submitting an exemption

I am under 22 years of age as of today and declining the vaccination for bacterial meningitis for reason of conscience, including religious belief; therefore a signed affidavit/waiver stating that I have declined for reason of conscience is being submitted.

Because of health related issues or efforts, it is the opinion of my physician that the vaccination required would be injurious to my health; therefore an affidavit or certificate signed by my physician who is duly registered and licensed to practice medicine in the U.S. is included with this form.

Affidavit may be obtained/notarized at: www.thecb.state.tx.us/reports

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Contact Information

First Name

Last Name

Email Address

Birth Date

I am 22 years of age or younger and I am attaching a copy of my official immunization record with this verification form indicating a current Bacterial Meningitis vaccination by a licensed health care provider authorized by law to administer the required meningitis vaccination (quadrivalent MenACWY-CRM meningococcal vaccine).

By submitting this form I am acknowledging that my information is current and accurate. I also give my permission for OLLU to share this information with appropriate school officials when deemed necessary.

Health Education Resource Office
Our Lady of the Lake University
411 S.W. 24th Street, Walter Student Services Center
San Antonio, Texas 78207
Fax: 210-431-4091
Phone: 210-431-3919
Email: healtheducation@ollusa.edu