Immunization Information Form

Student First Name *

Last Name *

Cell Phone Number *

Email Address *

Birth Date * +

Gender *

Male

Female

*All students are required complete the following information*

Faith Baptist Bible College requires proof of immunizations on file in Health Services prior to starting class in the fall. Please check the required immunizations carefully. You must have all of the following before you arrive on campus:

1 tetanus booster within the past 10 years
2 measles, mumps, and rubella vaccinations
1 tuberculosis test within the past year if you answer yes to any of the questions listed

Tuberculosis Testing - PPD Skin Test: For any student who can answer yes to the following. *

	Yes	No
Have you spent time with someone who has active TB disease?	Yes	No
Do you have an HIV infection?	Yes	No
Do you have symptoms of TB disease (fever, night sweats, cough, and weight loss)?	Yes	No
Were you born in or have traveled to Latin America, the Caribbean, Africa, Asia, Eastern Europe, or Russia in the past 5 years?	Yes	No
Do you live or work somewhere in the United States where TB disease is more common (homeless shelters, prisons/jails, or nursing homes)?	Yes	No
Do you use illegal drugs?	Yes	No

If any of the above apply, a PPD skin test
must be completed within the year.

Date of test: +

Result:

If you have propr history of a positive TB skin test, a negative chest x-ray is required. Please ask your doctor or hospital to send a copy of the report to Kim Nihart, RN at nihartk@faith.edu.

Meningitis Notification

While FBBC&TS has had no reported cases of meningitis, the State of Iowa has mandated that we make the following information available to our students:
Meningitis—Know Your Risk & Learn About Vaccination Some college students may be at risk for meningococcal disease, a potentially fatal bacterial infection commonly referred to as meningitis.
What is meningococcal meningitis? Meningitis is rare, but when it strikes, this potentially fatal bacterial disease can lead to swelling of fluid surrounding the brain and spinal column as well as severe and
permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation and even death.
How is it spread? It is spread through the air via respiratory secretions or close contact with an infected person. This can include coughing, sneezing, kissing, or sharing items like utensils/drinking glasses.
What are the symptoms? Symptoms of meningococcal meningitis often resemble the flu and can include high fever, severe headache, stiff neck, rash, nausea, vomiting, lethargy, and confusion.
Who is at risk? Certain college students, particularly freshmen who live in dormitories or residence halls, have been found to have an increased risk for meningococcal meningitis. Other undergraduates can also consider vaccination to reduce their risk for the disease.
Can meningitis be prevented? Yes. A safe and effective vaccine is available to protect against four of the five most common strains of the disease. The vaccine provides protection for approximately three to five years. As with any vaccine, vaccination against meningitis may not protect 100 percent of all susceptible individuals. The Advisory Committee on Immunization Practices (ACIP) along with the Centers for Disease Control (CDC) recommend college Students, particularly those living in dorms or residence halls, be vaccinated.
Whom do I contact for more information? To learn more about meningitis and the vaccine, contact Kim Nihart, RN in Health Services, or your health care professional. You can also visit the websites of the Center for Disease Control and Prevention (CDC) and the American College Health Association.

Meningitis Vaccine Information

Iowa State law requires FBBC&TS to inform you of the risks associated with meningococcal disease and the benefit of vaccination, and this information has been provided above. You may also obtain information from the Health Services office by emailing nihartk@faith.edu.

I was provided with information concerning meningococcal disease. I have read, and understand the risk associated with meningococcal disease, as well as the benefits of vaccination. *

I have received or am planning to receive the meningitis vaccination (Booster recommended if given age 16 or younger).

I choose not to receive the immunization at this time.

Date of Vaccine * +

COVID-19 Information:

I have received the COVID-19 Vaccination *

Yes

No

COVID-19

	COVID-19 1-shot vaccination
Date 1 (MM/DD/YYYY)	COVID-19 1-shot vaccination
OR - Had the disease	COVID-19 1-shot vaccination

COVID-19

	COVID-19 2-shot series
Date 1 (MM/DD/YYYY)	COVID-19 2-shot series
Date 2 (MM/DD/YYYY)	COVID-19 2-shot series
OR - Had the disease	COVID-19 2-shot series

Immunization Records

Required Immunizations - These must be completed before starting class. Please provide the month/day/year for each immunization, or attach a copy of the immmunization record (preferred).

I choose to continue providing information by: *

Entering my immunization records manually in this form.

Attaching all of my immunization record documents to this form. (Include copy of COVID vaccination card/form).

Claiming a medical or religious immunization exemption.

*continue on the next page*