Pre-Entrance Health Packet

Transcription

1 Pre-Entrance Health Packet Immunization, Medical History/Emergency Contact, Proof of Insurance, Physical Exam and Authorization for Treatment Office of Student Services 2/14/2013 This packet contains important immunization information, immunization and medical history forms, and information about health care expenses. Consult your physician, nurse practitioner, or contact Beacon College Student Services, at (352) , to speak with Debra D. Allen RN, MSN, Assistant Director of Health Services, for more information.

2 Beacon College Student Immunization Policy Required Immunization - In accordance with Florida Statute and Florida Administrative Code (6C ) along with promoting a healthy college community, Beacon College policy requires that prior to registration, housing assignments and attendance; all students must provide the following immunizations, documented by your health care provider: REQUIRED IMMUNIZATION College Policy requires the following immunizations for all students, documented by your health care provider. Health Care Provider must complete this section in English. Provide month, day and year of vaccine or dated copy of titers and reports. The following are required: 1. Two doses of measles, mumps, rubella combined in an MMR (2 doses after 1 st birthday) OR Laboratory reports of titers for immunity of measles (rubella), mumps and rubella. AND 2. Three doses of Hepatitis B vaccination at intervals of 1 month apart, and the third at six months from the first dose. The hepatitis vaccination series is not restarted. So if a dose is missed, the series can still be completed as a series of three; OR Laboratory reports with titers for antibodies to Hepatitis B. AND 3. One or Two doses Meningitis vaccination all students revaccinate every five years if increased risk AND 4. A booster dose of Tetanus, Diphtheria, Pertussis (Tdap/Adacel) within 10 years of this date 5. Tuberculosis Screening: Required for International Students & Students Residing outside of the United States as well as most Health Programs (see form) 6. Immunizations must be documented on Beacon College s Immunization form with an authorized stamp and signature of your health care provider. 7. Exemptions: Exemptions to the immunization policy (based on Florida State policy and / or College policy) may be granted for valid medical or religious reasons. STRONGLY RECOMMENDED for your Health! (But NOT required) Varicella #1 (Chickenpox) Varicella #2 (Chickenpox) or History of Chickenpox Disease Hepatitis A #1 Hepatitis A #2 HPV (Gardasil) #1, #2, #3 Polio (last dose date) 02/2013

3 Checklist If you can check off each of these checklist questions, you are ready to return all the information requested in your Pre-Entrance Health Packet: 1. Is all the information printed and legible? 2. Have I included my social security number? 3. Have I listed dates for two Measles, Mumps, and Rubella combined vaccinations? 4. Have I received a booster dose for Tetanus, Diphtheria, & Pertussis (Tdap/Adacel) within 10 years of this date? 5. Have I been immunized for Meningococcal Disease? 6. Did I receive a Meningococcal vaccine booster if vaccinated before the age of 16 yrs.? 7. Have I completed the Hepatitis B vaccination series? 8. If an international student or student who resides outside of the United States, have I received a Tuberculosis screening within the 12 months? 9. Has my doctor transcribed the requested immunization information, and officially stamped/signed the enclosed immunization form? 10. Is the Medical History and Emergency Contact form completed? 11. Completion of physical examination form by physician (exam must be within the last 12 months)? 12. Have I (or my parent if under the age of 18) signed the Authorization for Treatment form? Complete and send all documents as soon as possible to: Beacon College Attn: Debra D. Allen Student Services/Student Health Office 105 East Main Street Leesburg, FL Phone: (352) EFax: 1(800)

4 Important! Do Not Delay! Completed Immunization Form REQUIRED for you to obtain campus housing or register for classes at Beacon College! Obtaining proof of immunizations can be a Time-consuming process, so start now! Mail your verified immunization document to Beacon College Student Services/Student Health Office 105 E. Main St. Leesburg, Florida 34748, Attention: Debra D. Allen The Advisory committee on Immunization Practices (ACIP) has recommended that college freshman living in residence halls receive vaccinations for Meningococcal Meningitis. All new students must provide documentation of vaccinations against meningococcal meningitis and Hepatitis B or provide the college with a signed waiver for each declined vaccination. Please complete and return as soon as possible!

5 IMPORTANT IMMUNIZATION INFORMATION FOR ALL STUDENTS Many extremely valuable vaccines are available to help prevent certain diseases. Preventing any of the following diseases is highly desirable and is best accomplished with vaccinations. Important! Completions of some immunizations are required to comply with the Florida Statute and the Florida Admin Rule 6C-6.001(5). In some cases incomplete or inaccurate immunization information can interfere with a student s registration or attendance in class. Obtaining proof of immunizations may be a time-consuming process, so start now! MENINGOCOCCAL MENINGITIS is a severe form of bacterial meningitis that causes an infection of the brain and spinal cord. This bacterial infection, though rare, may cause severe neurological impairment, partial extremity amputations or even death (10-15% mortality rate). The American College Health Association and the Centers for Disease Control and Prevention recommend that students consider getting the meningococcal vaccine. Meningococcal vaccine enhances immunity to four strains of bacteria that cause 65-70% of the disease and lasts 3-5 years. Freshman living in residence halls, exposure to cigarette smoke, bar patronage and excessive alcohol consumption may further increase the risk of infection within the age groups. The incidence in young adults is 1.4 cases per 100,000 and 5.1 cases per 100,000 for college freshman living in dormitories. People should not receive this vaccine if they have ever had a serious allergic reaction to a previous dose of the vaccine. People with moderate or severe illnesses should usually wait until they recover to receive the shot. Meningococcal vaccine may be available through your local health department, your primary care physician. HEPATITIS B is a serious viral liver infection, prevalent worldwide, that can lead to chronic liver disease and liver cancer. Anyone who comes in contact with the blood or other body fluids (semen, vaginal fluids and saliva) of an infected person is at risk for this disease. The virus can also be spread from mother to baby during pregnancy and delivery. Hepatitis B vaccine is extremely safe and effective and can provide immunity against hepatitis B infection for individuals at risk. People should not receive the hepatitis B vaccine if they have ever had a life threatening allergic reaction to baker's yeast or to a previous dose of hepatitis B vaccine. People who are moderately to severely ill at the time of the shot should usually wait until they recover before getting the vaccine. Hepatitis B vaccine may be available from your local health department, your primary care physician. MEASLES is a highly contagious, acute viral infection characterized by a rash, cough, runny nose, eye irritation and fever. It is extremely communicable and is spread by droplets from the nose and mouth of an infected person to susceptible individuals. Measles can lead to ear infection, pneumonia, seizures, brain damage or even death. In recent years in the U.S., outbreaks have occurred most commonly in adolescents and young adults, including college students. Receiving two doses of the live measles vaccine can provide long-lasting immunity. Some people should check with their doctor about receiving the live vaccine, including anyone who: has HIV/AIDS or any disease that affects the immune system, is taking drugs that affect the immune system, has any kind of cancer or is receiving cancer treatment, has certain blood disorders or has recently received blood transfusions or blood products. Women known to be pregnant should not receive measles vaccine. RUBELLA is a contagious viral infection that causes a rash, mild fever and stiff joints in adults. A woman who gets rubella while pregnant could have a miscarriage or her baby could be born with serious birth defects. Its incidence is low in the U.S. due to the increased number of childhood vaccinations against the disease; however, outbreaks continue to occur in susceptible populations, including college students. The vaccination for rubella produces antibodies in over 95% of recipients. Women known to be pregnant should not receive rubella vaccine.

6 TETANUS/DIPTHERIA/PERTUSSIS Tetanus is an acute bacterial infection at the site of an injury to the body. Diphtheria and Pertussis are acute bacterial infections of the respiratory system which can have serious or life-threatening complications. The Tdap vaccine can protect against all three diseases and is recommended as a one-time booster. Subsequent booster vaccinations should be for Tetanus and Diphtheria only. Certain individuals may not be candidates for these vaccines. Please check with your health care provider. INFLUENZA is a serious viral disease that spreads from infected people to the nose and throats of others. Yearly flu shots (early October to mid-november) are recommended for everyone, but are especially indicated for anyone with asthma, chronic heart or lung disease, diabetes or other health problems that compromise the ability to fight infections. Please check with your family/shs physician or nurse practitioner. HUMAN PAPILLOMA VIRUS is a common sexually transmitted virus. HPV vaccine is recommended for young women under 25 years of age and adolescents. The prevalence in females under 25 years of age is between 28% and 46%. Complications of HPV include cervical changes that may take years to manifest genital warts and a genital cancer, particularly cervical cancer but also anal & some oral cancers. Cervical cancers and other complications of HPV are largely preventable through both education & a vaccine recommended by the advisory committee on immunization practices. Cervical cancer is associated with high morbidity (illness producing symptoms) and expense with treatment cost in excess of2 billion/year and more than 3000 deaths annually. HPV vaccine may be available through your local health department, your primary doctor of gynecology. VARICELLA or Chickenpox is a very contagious disease caused by the varicella-zoster virus. It causes a blister-like rash, itching, tiredness and fever. Chickenpox can be serious, especially in babies, adults and people with weakened immune systems. It is spread easily in the air through coughing or sneezing. It can also be spread by touching or breathing in the virus particles that come from chickenpox blisters. The best way to prevent this disease is to get the chickenpox vaccine. Before the vaccine, about 4 million people would get chickenpox each year in the U.S. HEPATITIS A refers to liver inflammation caused by infection with the hepatitis A virus (HAV). HAV is one of several viruses that can cause hepatitis, and is one of the three most common hepatitis viruses in the United States. Because of the way it is spread hepatitis A virus tends to occur in epidemics and outbreaks. The rate of infection has declined since 1999 from 6.3 to 0.9 per 100,000 people per 2008 CDC statistics. The virus is spread primarily person-to-person through the fecal-oral route. In other words, the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (stool) of an infected person. POLIO also called poliomyelitis is a contagious, historically devastating disease that was virtually eliminated from the Western hemisphere in the second half of the 20 th century. Polio is transmitted primarily through the ingestion of material contaminated with the virus found in stool. Not washing hands after using the bathroom and drinking contaminated water were common culprits in the transmission of the disease. Four countries (Afghanistan, India, Nigeria, and Pakistan) still have polio circulating, and the virus could be introduced to other countries. If the polio virus is imported into a country where not enough people have been immunized, there s the risk that it could spread from person to person. That s what has happened in some countries. So until polio has been eliminated worldwide, it s important to continue vaccinating kids against the disease.

7 Mandatory Immunization Form Complete and send this form to the address specified as soon as possible. Completion of this form is necessary to comply with the Florida Statute and the Florida Admin Rule 6C-6.001(5). This form is also available in the Office of Student Services. Please print clearly in black or blue ink pen. Carefully read the instructions before you complete this form; you will not receive your apartment key or be allowed to register at Beacon College until this document is received. Name: Male Female Last First Initial Date of Birth: Month Day Year Social Security Number: Term/Year for which you are applying: Fall Spring Year ***Meningitis Vaccine A. Immunizations required of ALL students entering Beacon College: MMR (Measles/Mumps/Rubella) Dose 1 Dose 2 -OR- Measles (Rubeola) Dose 1 Dose 2 Titer/Date ***AND Booster IF 1 st. dose of Meningitis Vaccine was given before 16 years of age: For international students ONLY: TB (Tuberculosis) Copy of lab report must be attached Rubella (German Measles) -AND- Titer/Date OR Hepatitis B (If Positive HepB surface antibody attach copy of lab results) Dose 1 Dose 2 Dose 3 Td (Tetanus/Diphtheria) Tdap (Tetanus/Diphtheria/Pertussis) OR Copy of lab report must be attached B. Immunizations recommended for good health: Mumps HPV Polio (last dose) Varicella (Chicken Pox) 2 shots or date of illness Dose 1 Dose 2 Date of Illness Hepatitis A Dose 1 Dose 2 OR C. An official stamp from a doctor s office, clinic, or health department AND an authorized signature must appear on this form. Name of Public Health Clinic or Physician (facility stamp) Physician or Authorized Signature Date Send or fax form as soon as possible to: Attention: Debra D. Allen Beacon College, Student Services 105 East Main St. Leesburg, FL OR- EFax (800) Phone (352) PLEASE KEEP A COPY FOR YOUR RECORDS

8 Date: Medical History and Emergency Contact Form Personal Data please print legibly in blue or black ink. Name: Male Female Last First Initial Date of Birth: Month Day Year Social Security Number: Height: Weight: Cell Phone: Will reside in campus housing? YES NO Term/Year for which you are applying: Spring Fall Emergency Contact: Phone 1: Phone 2: Personal Medical History please print legibly in blue or black ink. Do you have any allergies? Yes No If yes, please specify. Include medications, insect bites, environmental factors and food allergies. Do you smoke? Yes No Do you use other tobacco products? Yes No Do you consume alcohol? Yes No Please indicate below if you are being treated or have been treated in the past for any of the following and indicate the year. Attach a physician statement/summary for any items checked, except chicken pox. YEAR YEAR ADD/ADHD Epilepsy, Seizures Alcohol/Drug Dependency Head Injury Anemia, Blood Disease Heart Murmur/Disease Anxiety/Depression Hepatitis Arthritis, Joint Disease, Bone Disease High Blood Pressure Asperger s Disorder Hypoglycemia (low blood sugar) Asthma Lyme Disease Bipolar Disorder Malaria Blood Clot/Phlebitis Migraines Cancer Rheumatic Fever Chicken Pox Schizophrenia Diabetes (indicate type) Thyroid Disease Digestive Disorder Tuberculosis Personal Physician: Name Address Phone Are you currently under the care of any clinical practitioner for any other medical conditions? Yes No Medications (include birth control, vitamins, herbs and dosage, times/day, a.m./p.m., etc.): List operations and/or hospitalizations (include reason and year): Mental Health History: Please answer all questions. Have your academic and/or work activities ever been interrupted because of mental health or emotional problems? Please explain: Have you ever been treated with any medication for psychiatric reasons? Please explain: Have you ever been hospitalized for mental or emotional problems? Please explain: No Yes No Yes No Yes Signature: Date:

9 Authorization for Treatment I hereby grant permission to the staff of Student Services/Health Services of Beacon College to render any first aid/health care or emergency treatment to myself (son/daughter). I also grant permission for the above referenced Beacon College staff to arrange health care, emergency treatment or hospitalization at an accredited hospital or medical, psychological or dental care facility when considered necessary. Student Signature Date Parent/Guardian (required if student is under 18) Date

10 Health Insurance and Health Care Expenses Verification of health insurance must be submitted upon enrollment then annually for all students, please be sure to put a date on the copy of your student s insurance card (front and back). All medical expenses incurred by students are the responsibility of the individual student. Therefore it is required that all students carry health insurance. When submitting the required forms and documentation to Beacon College personnel, please attach a copy, front and back, of your insurance card Please be aware that if you are insured by an HMO (Health Maintenance Organization), you might not be covered for non-emergency services while on campus and outside the plans network. We urge you to contact your plan administrator for details on your coverage. Also, some health plans are PPO s (Preferred Provider Organization) and require that you use preferred clinicians for off campus care that you might require while attending Beacon College. Your plan administrator can provide you with a list of the providers for Leesburg, FL and surrounding areas. Please let us know right away if you have no insurance coverage, we are able to provide you with insurance options through the American College Student Association (ACSA). INSURANCE INFORMATION All students are required to have health insurance complete information below and a copy of the insurance card (front/back) must be on file. Insurance Company: Name Policy Number Address Group Number City/State/Zip Telephone Number Policyholder: Employer Social Security Number I hereby assign the benefits of my insurance policy to designated health care providers as appropriate. I understand that I am responsible for all charges that are not paid by that policy. I authorize the release of information needed to my insurance company in order to consider payment of my claim for services rendered. I understand that this assignment and authorization will remain in effect indefinitely or until such time that I give written notice to the contrary. Policyholder signature: Date: Required: copy of front/back of insurance card

11 Student Name Last First MI Date of Birth PHYSICAL EXAM: Required of ALL new incoming students and yearly for athletes. Any athlete without a current physical will be unable to participate in sports. Your health care providers physical form signed and dated within the last year will be acceptable. Please list any chronic illness or significant past medical history: Please list current medications and dosages: Allergy to Medication, Food or Insect bites: Surgical Hx: Height: Weight: BP / Pulse Skin H.E.E.N.T. Neck/Thyroid Lymph glands Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurologic Psychological NORMAL ABNORMAL Comment on abnormal Recommendations for Physical Activity: Unlimited: If limited, please explain: HEALTH CARE PROVIDER: Signature Name (or stamp) Address Limited: Date of Exam Phone# Fax#

12 TUBERCULOSIS RISK QUESTIONNAIRE (International Students & Students Residing outside of the United States only) Student Name Date of Birth Last First MI YES NO 1. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)? 2. Were you born in one of the countries listed below? 3. Have you traveled or lived for more than one month in one or more of the countries listed below? COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)* * W orld Health Organization. Global tuberculosis control. WHO report Afghanistan Congo Kazakhstan Niue Thailand Algeria Côte d'ivoire Kenya Northern Mariana Islands Timor-Leste Angola Democratic People's Kiribati Pakistan Togo Armenia Democratic Republic Lao People's Palau Turkmenistan Azerbaijan Djibouti Latvia Panama Tuvalu Bangladesh Dominican Republic Lesotho Papua New Guinea Uganda Belarus Ecuador Liberia Peru Ukraine Belize Equatorial Guinea Libyan Philippines United Republic of Benin Eritrea Lithuania Republic of Korea Uzbekistan Bhutan Ethiopia Madagascar Republic of Moldova Vanuatu Bolivia (Plurinational State Gabon Malawi Romania Viet Nam Bosnia and Herzegovina Gambia Malaysia Russian Federation Yemen Botswana Georgia Mali Rwanda Zambia Brazil Ghana Marshall Islands Sao Tome and Principe Zimbabwe Brunei Darussalam Greenland Mauritania Senegal Thailand Burkina Faso Guam Micronesia Sierra Leone Timor-Leste Burundi Guatemala Mongolia Solomon Islands Togo Cambodia Guinea Morocco Somalia Turkmenistan Cameroon Guinea-Bissau Mozambique South Africa Tuvalu Cape Verde Guyana Myanmar South Sudan Uganda Central African Republic Haiti Namibia Sri Lanka Ukraine Chad Honduras Nepal Sudan China India Nicaragua Suriname China, Hong Kong SAR Indonesia Niger Swaziland If you answered YES to any of the above questions, you are considered high-risk and are required to submit documentation of recent PPD testing on the Immunization form. PPD testing should be within the last 12 months. If the Mantoux PPD test is positive ( 10mm), you must submit a copy of a chest x- ray report in English dated within the last 6 months. Please note: If you have had a positive tuberculin skin test in the past, you do not need another test. Please note prior treatment completed.