Vaccination and Tuberculosis Form for RU Students

Your Information

Rockhurst ID (example: @00123456) Please enter @00 and your six digit ID number

First Name

Last Name

Birthdate (this is required for data matching)

Rockhurst Email Address

Rockhurst Student Status

Current Rockhurst Student, I have already attended classes on the Rockhurst campus or online

New Student, first semester to attend Rockhurst classes and/or lived on campus

Will you be living on campus?

Yes

Vaccination Records

Have you had your Measles, Mumps and Rubella (MMR) vaccinations?

Yes

This vaccination is required for all students who live on campus unless it has been waived for religious reasons.

I am exempt from vaccinations due to religious exemptions. I voluntarily agree to release, discharge, indemnify and hold harmless Rockhurst University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury to myself or others that might result from my decision NOT to be immunized.

Place today's date in the box as a confirmation of this waiver.

MMR Date of First Injection

MMR Date of Second Injection

Have you had your Meningitis vaccinations?

Yes

This vaccination is required for all students who live on campus unless it has been waived.

Meningitis Date of Injection

Was the first meningitis vaccination injections administered at 16 years of age or older?

Yes

Since the first meningitis vaccination injection was administered while the student was under the age of 16, a booster vaccination is required. Date of booster:

Meningitis Waiver
I understand the meningitis vaccine is now recommended for all young people. I acknowledge that meningitis disease is a rare, but life-threatening illness. I understand that under Rockhurst's policy, all students living on Rockhurst campus are required to be vaccinated against meningitis disease. With this waiver, I seek exemption from this requirement. I voluntarily agree to release, discharge, indemnify and hold harmless Rockhurst University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from my decision NOT to be immunized against meningitis.

Enter today's date in acknowledgement of this waiver to NOT be immunized.

The University encourages all students to be up to date on their COVID-19 vaccination(s) prior to living on campus.

Tuberculosis Screening

Tuberculosis testing is required for high risk students. To determine high risk status, please read each option carefully and check the most recent risk factor or the option 'none'.

Been a health care worker

Born in Asia, Africa, Central or South America or Eastern Europe

Had contact with a person known to have active Tuberculosis

Lived for 2 or more months in Asia, Africa, Central or South America or Eastern Europe

Volunteered or worked in a nursing home, prison or other residential institution

None of these apply. I am not at high risk.

Tuberculosis Testing Required
Further testing, such as a TB Skin Test or TB blood test, will be determined by risk factors and screening results. If available, provide written documentation of TB screening (Mantoux skin test documented in millimeters of induration) done in the US within the past 12 months or prior TB blood test results. If prior treatment for active TB disease or latent TB infection has been completed, written documentation must be submitted.

Upload TB Screening Documentation

By clicking Submit, I affirm and certify that all the information and answers to questions herein are
complete, true and correct to the best of my knowledge and belief. I understand that any
misrepresentation, falsification, or omission of any facts in the completion of this form may be cause for termination or expulsion and/or other disciplinary action, whenever discovered.