Madison College School of Health Education. Health Forms & Immunization Requirements

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1 Madison College School of Health Education Health Forms & Immunization Requirements It is important that you know your immunization history. You will need your vaccination record to complete your health forms. How to Locate Your Vaccination Records Check with your health care provider(s); start with the clinic used as a child. Contact your local public health department. Look through saved documents from your childhood (doctor visit records, baby book, etc.) Check with your high school and/or college health services if you previously attended college at another institution. Check with current and previous employers - including the military. Check Wisconsin s Immunization Registry. The Wisconsin Immunization Registry (WIR) at dhs.wisconsin.gov/immunization/wir International students: You may have an immunization record with your passport as it often is required for entry into other countries. What To Do If You Can't Find Your Records If you can t find your health records, you may need to get some of the vaccines again. While this is not ideal, it is generally safe to repeat vaccines. You may have blood tests performed to see if you are immune to certain vaccine-preventable diseases. These tests can become costly and are not covered by the Student Health Services Plan. You may want to have these blood tests done through your primary care clinic where you have health insurance to avoid having to pay out of pocket expenses. For Students Using Their Own Health Care Provider/Clinic If you are having your health forms filled out by your own health care provider, please have them determine and administer any additional immunizations you may need to meet your program requirements. For Students Using Student Health Services at Madison College After you have gathered your vaccine history (please print these) you can fill out your health history forms. Attach proof and medical documentation with your forms. If you need assistance, contact: Madison College Health Educator Anna Marie Hoffmann, RN at or by at ahoffmann@madisoncollege.edu. *The clinic will review your forms and provide TB skin tests at no charge for students who are enrolled in a health occupation course that is a degree-credit course at Truax, Downtown, or the South Campus. Any immunizations or lab tests yet needed are available for a fee. Prices vary. Please ask the clinic staff for more information or visit madisoncollege.edu/health

2 MADISON COLLEGE Health Screening Form To be submitted to CLINICAL REQUIREMENTS STEP ONE (COMPLETED BY STUDENT) STUDENT INFMATION Student Name Date of Birth Program Campus Location Please share information on any allergies, illnesses or disabilities that would require reasonable accommodations. Examples of these are: lifting restrictions, latex glove allergies, skin allergies, hearing impairment, diabetes, or drug allergies. Review your program s functional abilities for specific expectations. Please explain in detail below: STATEMENT OF UNDERSTANDING I hereby give permission to release information on this health form to my specific program faculty including clinical/fieldwork faculty and School of Health Education staff. Health insurance is mandatory for participation in clinical. You will be asked to indicate your health insurance status on the CastleBranch site (yes/no). Please see School of Health Education website regarding basic accident insurance enrollment options. I understand that I must meet program-specific deadlines for submission of complete Health Screening and Background Check documents or I could jeopardize my eligibility to participate in clinical experiences. Student Signature Date Page 1 of 4 23 August 2016

3 Student Name STEP TWO (COMPLETED BY HEALTH CARE PROVIDER) Madison College does not require a full physical examination; this is a basic health screening. MMR MEASLES (RUBEOLA)/MUMPS/RUBELLA VACCINE One of the following is required: 1) two vaccination dates, a minimum of 28 days apart. 2) a positive titer lab report for Measles, Mumps, and Rubella. NOTE: If the titer is negative or equivocal, you must document two MMR vaccinations. Date of MMR Vaccines: Measles Titer Mumps Titer Rubella Titer #1 #2 VARICELLA (CHICKEN POX) VACCINE One of the following is required: 1) two vaccination dates, a minimum of 4 weeks apart. 2) a positive titer lab report. NOTE: If the titer is negative or equivocal, you must document two vaccinations. Date of Varicella Vaccines: Varicella Titer #1 #2 HEPATITIS B VACCINE One of the following is required: 1) documentation of three vaccinations. 2) a positive titer lab result. NOTE: if the titer is negative or equivocal, you must complete and document a three-dose vaccine series. NOT required for: Medical Coding Specialist, Optometric Technician, Therapeutic Massage, and Nursing Assistant (recommended due to exposure risk, but not required) programs. Date of Hepatitis B Vaccines: #1 #2 #3 Hepatitis B Titer Page 2 of 4 23 August 2016

4 Student Name TUBERCULOSIS SCREENING One of the following is required: 1) a 2-step skin test (1-3 weeks apart). This requires a minimum of four doctor visits; dates placed, dates read and results must be documented. 2) Three consecutive annual test results; with no more than 12 months between tests and most recent test within the past 12 months*. 3)QuantiFERON or T-SPOT.TB test results reflecting negative TB status. 4) In the case of positive TB test results, a negative (clear) chest x-ray must be provided. NOTE: renewal date is set for one year. TB Skin Test Step 1 Injection Date: Read Date: Result in mm: TB Skin Test Step 2 (min. of 1 week later) Injection Date: Read Date: Result in mm: option #2 Dates of Annual Skin Test *NOTE: this form of documentation is insufficient for Surgical Technologist program; must submit documentations of 2-step skin or blood test. option #3 Please check one: QuantiFERON Gold () T-Spot Test #1: option #4 If history of positive TB test, provide chest x-ray results: (<1 Year Ago) #2: ( 1 year since #1) #3: ( 1 year since #2) Test Date: Result: Circle one: positive, negative or indeterminate X-Ray Date: Result: NOTE: Positive (unclear) chest X-Ray results may affect your ability to participate in program; please contact Program Director. NOTE: If you have undergone treatment for TB, please contact your Program Director. TETANUS/DIPHTHERIA/PERTUSSIS VACCINE (TDAP) TETANUS/DIPTHERIA (TD) VACCINATION TDap or TD booster within the past 10 years. Date of TDAP or TD vaccine: Student Name Page 3 of 4 23 August 2016

5 INFLUENZA (FLU) VACCINE SEASONAL Required: a flu shot administered during the current flu season. The renewal will be set for the start of the next flu season. NOT required for: Dental Assistant, Dental Hygienist, Optometric Technician and Therapeutic Massage programs. Date of Seasonal Influenza Vaccine: Declination Waiver: I am declining an influenza vaccine and understand this may prohibit my participation in clinical and successful completion of my program. Student Signature: Reason: Note: Influenza vaccine not required for clinicals May to September. If only participating in a summer clinical, check here HAS THIS STUDENT BEEN TREATED F TESTED POSITIVE F ANY OF THE FOLLOWING: Lifting Restrictions YES NO Latex Sensitivity YES NO If yes, please attach detailed explanation on clinic letterhead for each. Any special accommodations for this student based on student s screening? If yes, please attach detailed explanation on clinic letterhead for each. YES NO HEALTH CARE PROVIDER SIGNATURE AND CONTACT INFMATION By signing this form, you are indicating the information on this form is accurate and complete. Please ensure all lab reports are attached as required. If you have questions while completing this form, please call the Madison College School of Health Education office at Signature of Person Performing Health Screening (REQUIRED) Date Print Name and Title Clinic or Office Phone Number Address City State Zip Page 4 of 4 23 August 2016