HOWARD UNIVERSITY STUDENT HEALTH CENTER. Checklist of Immunizations/TB tests/medical History/Physical Exam

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1 Checklist of Immunizations/TB tests/medical History/Physical Exam Note: this checklist must be submitted with the immunization/tb testing forms Please complete ALL of the requirements below and check off what has been done, before submitting these forms. Partially completed forms will cause additional delays in registration. TUBERCULOSIS (TB) screening test within 6 months of starting at Howard University. Either a PPD or a TB blood test are acceptable. o All: Please see the Frequently Asked Questions page for more details, if necessary o Note that the date of placement and the date of reading are required. If positive PPD or TB blood test: Is chest X-ray result attached? HEALTH SCIENCES MAJORS: TWO-STEP PPD or TB blood test required. See FAQ page below TETANUS requirement a Tdap is required within the past 10 years. Note that a Td is no longer acceptable without at least one Tdap. MMR (Measles, Mumps, Rubella): Two (2) vaccines after your first birthday. HEPATITIS B SERIES Three (3) doses must be documented following the appropriate schedule. VARICELLA Two (2) Varicella vaccines OR history of chicken pox documented by a medical provider with month/year of disease MENINGOCOCCAL Mandatory for all first-time-in-college students. A booster dose is required after the age of 16. HIGHLY recommended for all other students (especially health sciences students) due to outbreaks of meningococcal disease on college campuses. POLIO 3 Polio vaccines are required for anyone under the age of 18 at the time of registration MEDICAL HISTORY FORM PHYSICAL EXAM FORM (REQUIRED FOR HEALTH PROFESSIONS STUDENTS NURSING/ALLIED HEALTH, PHARMACY, DENTISTRY, MEDICINE) ARE ALL FORMS SIGNED THAT NEED TO BE SIGNED?

2 2139 GEORGIA AVENUE NW, WASHINGTON, DC Phone (202) / Fax (202) Name (Last, First, Middle) Date of Birth (mm/dd/yr) Student Identification Number TUBERCULOSIS SCREENING IS REQUIRED FOR ALL STUDENTS. TB blood test must be performed or a PPD-Mantoux test must be placed and interpreted by a healthcare provider within 6 months of registration A student previously given the BCG vaccine should also receive the PPD skin test or have a TB blood test If the skin test is positive or the student has a history of a positive skin test, a copy of chest x-ray results within the last 6 months is required A TWO STEP PPD IS REQUIRED FOR ALL HEALTH PROFESSION STUDENTS IF THEIR LAST PPD WAS PLACED MORE THAN ONE YEAR AGO; TB blood test can be used in place of Two-Step. ALL STUDENTS: Date PPD Skin Test Placed: / / TB test must be within 6 months of registration Date PPD Skin Test Read: / / Result: mm HEALTH PROFESSION STUDENTS: Date 2 ND PPD Skin Test Placed: / / 2 nd TB test must be 1-3 weeks after 1 st test Date 2 ND PPD Skin Test Read: / / Result: mm TB BLOOD TEST Circle: (Quantiferon Gold/T-spot) TB test must be within 6 months of registration Date of TB blood test: / / Please attach copy of blood test Result: IF SKIN/BLOOD TEST POSITIVE, OR HISTORY OF POSITIVE TEST: Date of Chest X-Ray: / / ATTACH A COPY OF CHEST X-RAY REPORT Patient received INH: No Yes Duration of treatment: Months REQUIRED IMMUNIZATIONS: POLIO Three doses of polio vaccine are required for anyone under the age of 18 at the time of registration. TETANUS / DIPHTHERIA Three doses of Diphtheria/Tetanus/Pertussis (DPT, DTaP, or DT) in childhood and a booster of Tetanus/Diphtheria (Td) within the last 10 years. Note: MUST HAVE AT LEAST ONE Tdap MEASLES / MUMPS / RUBELLA (MMR) Two doses required. History of disease is not acceptable. If you were born before 1957 and are not enrolled in health sciences, you are exempt from the MMR requirement. HEPATITIS B Three doses required. VARICELLA Two doses required. History of chickenpox is acceptable only when it is documented by a medical provider with month/year of disease. MENINGOCOCCAL Booster required if primary dose given before 16 th birthday. Date of Td Booster / / Tdap Dose (REQUIRED) / / Dose (1) / / Dose (2) / / Booster / / enter booster date Booster (1) / / Booster (2) / / Booster (3) / / enter booster date(s) Dose (1) / / Dose (2) / / Booster / / History of Chickenpox / / enter booster date Date of Dose / / If 1 st dose before 16, then, date of Booster / / HEALTH PROFESSIONS STUDENTS ONLY In addition to the information above, you must submit blood titers (IgG QUANTITATIVE antibodies) for MMR, Hepatitis B, and Varicella. If MMR, Hepatitis B, or Varicella blood titers are non-immune, you must submit documentation (above) of dates for one of the following: dates for previously completed MMR, Hepatitis B, or Varicella vaccine plus a booster dose OR all required doses of vaccine with at least one dose given after the non-immune titer. Repeat titers > 1 month after last dose given. MEASLES / MUMPS / RUBELLA (MMR) Date MMR titers: / / Result: Measles Mumps Rubella HEPATITIS B Date Hepatitis B titers: / / Result: Hepatitis B titers VARICELLA Date Varicella titer / / Result: Varicella titers: Print Name of Health Care Provider or Clinician Signature REQUIRED / Health Department Stamp Date Office / Clinic Name Office / Clinic Address Telephone # RETUN OR FAX TO: HOWARD UNIVERSITY STUDENT HEALTH CENTER 2139 GEORGIA AVENUE, NW, Washington, DC / Fax (202)

3 NAME Last First Middle HOME ADDRESS Street City, State/County Zip Code HOME PHONE NUMBER (Include area code) ADDRESS (if available) SEX: Female Male DATE OF BIRTH UNDERGRADUATE GRADUATE Month/day/year SPECIFY PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: Name Relationship Phone Address Street City State/Country Zip Code PARENTS OF STUDENT UNDER 18: PLEASE COMPLETE THIS SECTION I, the undersigned, parent/legal guardian of, a minor, do hereby consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital service that may be rendered to said minor, under the instructions of the Howard University Student Health Center, whether such diagnosis or treatment is rendered at the office of said physicians or at a hospital licensed by the District of Columbia. Signature of Parent /Legal Guardian Date

4 Name HOWARD UNIVERSITY STUDENT HEALTH CENTER Student ID FAMILY MEDICAL HISTORY: Please indicate all biological family members who have experienced any of the following conditions. If deceased, age at time of death (i.e., asthma, paternal grandfather, 96) Condition Biological Family Member If Deceased, Age Asthma Cancer (type) High Blood Pressure Diabetes Heart Disease High Cholesterol Thyroid Condition Tuberculosis Alcoholism Other (specify) PERSONAL MEDICAL HISTORY Any allergies (medication) (food) (others) Tobacco Use Yes No Pack a day Years I quit ago Other tobacco products (specify) Alcohol Use Yes No How Often Quantity/Amount Mental Health History (please specify): Substance Abuse History (please specify): List any surgery, hospitalizations (including psychiatric), illnesses, significant injuries and approximate dates: Surgery Hospitalizations Illnesses Injuries Dates List any medications you are taking (including birth control pills/non-prescription pills): Please describe any ongoing medical problem? For women only: most recent pap and pelvic exam if any (date and result): Student s Signature Date

5 Frequently asked questions about immunizations and TB testing What is a medical hold? Why do I have one and what are the consequences of medical holds? New entrants, transfer students or former students returning: once you have been accepted to Howard University and have paid your enrollment fee, you are automatically placed on medical hold until you satisfy the immunization and Tuberculosis screening requirements. Only after satisfying all of the requirements will your medical hold be removed. At this point you will be able to register for classes. I do not have shot records. Do I have to take all of the immunizations again? If you do not have documentation of some or all of your vaccines, you have several options: Try to see if the health department in your state has records of the vaccines Do blood titers for Measles, Mumps, Rubella, Hepatitis B and Varicella o If you have demonstrated immunity to all of those, you will not need to repeat the vaccines, but if you are not immune, you will need to be re-vaccinated with the ones to which you are not immune If you are over 18, we will not require documentation of polio vaccinations You will need a Tdap and likely a Meningococcal vaccine, plus a TB test Should I get the vaccines before I arrive or can I get them once I arrive? Historically, there have been large numbers of students who have had incomplete vaccination records who come to the Student Health Center to get the last ones. We discourage that for several reasons: The earlier the health requirements are met, the earlier the student can register for classes. The earlier they register, the more classes are available at preferred times There have been very long wait times in the health center to get the vaccinations, and if there is a two-step process (to get vaccinations and a PPD placed one day and the PPD reading a few days later), that can lead to a lot of unnecessary time that the student needs to wait. However, if the student has no other option to complete the vaccination series early, they are welcome to receive them at the Student Health Center. Fall students may receive them starting Aug 1, and Spring enrollees may receive them on the first clinic day after January 1. I m a health professions student. What does it mean to do titers? Titers are a blood draw to demonstrate that you have immunity to the diseases you ve been vaccinated against. It could be that after you have gotten the vaccine, your immunity has faded. As a health professional, we need to be certain that we are protected. If you are non-immune to the disease, we will need to be re-vaccinated (called a booster dose). Repeat titers should be done at least 1 month after a booster shot. What are common mistakes made with the Immunization/TB form? Form not signed by a provider PPD date of placement AND date of reading not noted PPD reading took place >3 days after placement PPD was performed > 6 months before registration Measurement of PPD not done (should be read as 0 mm, or 8 mm, etc.) Two-step PPD not performed for health professions students Titers not performed for health professions students No booster doses given when titers are non-immune Not sending in complete documentation to support data (ex: no chest x-ray report, incomplete shot record) Students don t keep a copy of the form or bring a copy to the health center

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