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Meningococcal and Hepatitis B Vaccination Status Form
Meningococcal and Hepatitis B Vaccination Status Form
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This form is for students living on campus to indicate if they have received the Meningococcal and Hepatitis B Vaccinations
Date of Birth
(mm/dd/yyyy)
Meningococcal vaccine received
No
Yes
Hepatitis B vaccine received
No
Yes
Vaccine Information
By submission of this form, I, the undersigned (if 18 years of age or older) or parent (if under 18), have read and understand the information provided to me about Meningococcal Meningitis and Hepatitis B. I understand the benefits and risks of being vaccinated against these diseases. The information below regarding my/my child’s vaccination status is accurate and is being provided in compliance with the Ohio Revised Code, Section 3701.133, (B).
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Your name
Your first name
Your last name
Your email address
Verification Code