Missouri Western State University Immunization / Screening Requirements For Students

Transcription

1 Missouri Western State University Immunization / Screening Requirements For Students Please read carefully. For questions, please call Esry Student Health Center at (816) ; Fax (816) or e- mail to health@missouriwestern.edu/. Additional information can be found at Instructions 1. Read the Missouri Western Immunization Guidelines below. 2. Part I is a Missouri State Mandated Law and must be completed by All Students. 3. Part II is a Missouri State Mandated Law and must be completed by All Students Living on Campus. 4. Complete immunization waiver, if applicable. 5. Forms are available at 6. Mail, fax or completed Tuberculosis Screening Questionnaire Form, Immunization Documentation Form and if applicable, a Waiver to: Esry Student Health Center Missouri Western State University 4525 Downs Drive Blum 203 St. Joseph, M health@missouriwestern.edu Fax: (816) Part I Tuberculosis Screening Questionnaire Required for all Students Missouri Western State University requires Tuberculosis Screening Questionnaire for All Students. 1. Complete the Tuberculosis Risk Assessment Form. Information available at: Part II Meningococcal Immunization Required for Students Living on Campus Missouri Western State University requires Students Living on Campus to either: 1. Show documentation of Meningococcal Immunization (MCV4 or MPSV4) given at 16 Years of Age or lder r 2. If applicable, sign a waiver that indicates you have medical or religious exemption from the meningococcal immunization. Information available at: Part III Immunizations HIGHLY RECMMENDED, but not required, for all University students **The CDC and the American College Health Association recommend that all university students be vaccinated with both the required and recommended immunizations to protect them against communicable disease. Information available at:

2 Missouri Western State University HIGHLY recommends that all newly enrolled or readmitted campus housing students show documentation of: Measles/Mumps/Rubella (MMR): Students born after December 31, 1956 comply with a two-dose Measles, Mumps, and Rubella Immunization Policy. Requirement: 2 doses of MMR vaccine. The first dose must have been given at age 12 months or later. The second dose must have been given at least one month after the first one. r, titer (blood test) results proving immunity to measles (rubeola), mumps and rubella. Documentation is required. Serogroup B Meningococcal Vaccine (MenB): (2-3 doses) Even if incomplete, provide dates of any doses Tetanus/Diphtheria/Pertussis (Tdap): within the last 10 years. Hepatitis A: (2 doses) of hepatitis A or (3 doses) of combined hepatitis A and B series Hepatitis B: (3 doses). Even if incomplete, provide dates of any doses received. Varicella (chicken pox): No vaccine is needed if there is a good history of natural infection. If history is questionable, a blood test can be done to determine immune status. Polio: Primary series (4 doses) IVP (injected Salk vaccine) Influenza vaccine: Available each fall and advisable for all students but in particular those with Asthma or any other chronic illness. HPV (human papillomavirus): (3 doses) through 26 years of age, if not given prior to college. (10/2016)

3 TUBERCULSIS (TB) SCREENING QUESTINNAIRE Name: Last Name (Please print) First Name & MI (Please print) G Number Phone Number (cell or home) Upon matriculation at Missouri Western State University, all students will complete the TB screening questionnaire in compliance with Missouri State Law. Upon hiring at Missouri Western State University, all faculty and staff will complete the TB screening questionnaire to aid in prevention and control of Tuberculosis. If testing is required, the process could take up to two weeks to complete. D NT WAIT UNTIL THE LAST MMENT. Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and, sometimes, other parts of the body. It is spread when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby. For additional information on TB: PLEASE CIRCLE YES R N T THE FLLWING QUESTINS: 1. Have you ever had a tuberculosis (TB) test that was positive, been diagnosed with or treated for TB disease? YES N 2. Have you ever been a health care worker, volunteer, or employee of a nursing home, prison, homeless shelter, or other residential institution? YES N 3. Have you ever been in close contact with someone known to have active tuberculosis (TB) YES N 4. Were you born in a country listed on the second page of this form? (If you were born in the United States of America, please check N ) Please list country of birth: YES N 5. Have you ever spent more than 2 months at one time in a country on the list? YES N Please list the country: If you answered YES to any of the above questions, you are required to provide documentation of further testing and evaluation by a certified U.S. Healthcare Provider. Students may contact the Esry Student Health Center for follow up. 1. You will be required to undergo a TB blood test instead of a TB skin test, if you were born in a country on the list or have received the BCG vaccination, due to the risk of a possible false positive. 2. If you have had a past positive TB test, you will need to present documentation of a chest x-ray within the last year or obtain one through a U.S. certified healthcare provider and have results submitted to the Esry Student Health Center. 3. If you have received prior treatment for active TB disease, you will need to provide proper documentation of such treatment to the Esry Student Health Center. All student tests can be obtained at the Esry Student Health Center (for students), or by a U.S. certified health care provider. All medical expenses will be the individual s financial responsibility. To the best of my knowledge, the information provided above is true and complete. I acknowledge that non-compliance will result in students not being eligible to enroll for a subsequent semester; faculty / staff members may not work on campus until screening is complete, per Missouri Western State University policy and Missouri law. Signature _Date_ If a student is under the age of eighteen (18), signature of a parent or legal guardian: Parent or legal guardian s signature _Date_ Return this form to Esry Student Health Center, Missouri Western State University, 4525 Downs Drive, St. Joseph, M or to the Human Resources Department if you are new faculty/staff. Fax: (816) health@missouriwestern.edu Revised 6/22/17

4 WH Countries with High Tuberculosis Incidence Rates (World Health rganization Global Tuberculosis Control, Countries listed are at a 20 per 100,000 Incident Rate or higher Afghanistan Guatemala Panama Algeria Guinea Papua New Guinea Angola Guinea-Bassau Paraguay Anguilla Guyana Peru Argentina Philippines Armenia Haiti Portugal Azerbaijan Honduras Qatar Bangladesh India Belarus Indonesia Romania Belize Iraq Russian Federation Benin Rwanda Bhutan Kazakhstan Bolivia Kenya Sao Tome & Principe Bosnia & Herzegovina Kiribati Senegal Botswana Korea-DPR Serbia Brazil Korea-Republic Sierra Leone Brunei Darussalam Kuwait Singapore Bulgaria Kyrgyzstan Solomon Islands Burkina Faso Somalia Burundi Lao PDR South Africa Latvia South Sudan Cabo Verde Lesotho Sri Lanka Cambodia Liberia Sudan Cameroon Libya Suriname Central African Republic Lithuania Swaziland Chad Syrian Arab Republic China Madagascar China, Hong Kong SAR Malawi Tajikistan China, Macao SAR Malaysia Tanzania-UR Colombia Maldives Thailand Comoros Mali Timor-Leste Congo Marshall Islands Togo Cote d Ivoire Mauritania Tunisia Mauritius Turkmenistan Djibouti Mexico Tuvalu Democratic Rep. of the Congo Micronesia Dominican Republic Moldova-Rep. Uganda Mongolia Ukraine Ecuador Montenegro Uruguay El Salvador Morocco Uzbekistan Equatorial Guinea Mozambique Eritrea Myanmar Vanuatu Estonia Namibia Venezuela Ethiopia Nauru Viet Nam Nepal Fiji New Caledonia Yemen Nicaragua Zambia Gabon Niger Zimbabwe Gambia Nigeria Georgia Northern Mariana Islands Ghana Greenland Pakistan Guam Palau

5 Esry Student Health Center Blum 203 Ph (816) Fx (816) IMMUNIZATIN DCUMENTATIN FRM Last Name First Name MI Male Female G-number Address City State Zip ( ) ( ) Phone Cell Phone Date of Birth Age Must Be Completed and Signed By Your Health Care Provider REQUIRED IMMUNIZATIN for MWSU students living on campus ***Required immunizations are for your protection against these communicable diseases and area required by Missouri State Law. 1. Meningococcal Immunization Proof of receipt of the Meningococcal Vaccine given at 16 years of age or older. MCV or MPSV4 / / Health Care Provider (signature required) To the best of my knowledge, the person above has received the above immunizations. Name: Signature: (Please print) Address: Street/P.. Box City: State Zip Phone: ( ) Date: HIGHLY RECMMENDED IMMUNIZATINS (but not required) for all MWSU students. ***Recommended immunizations are for your protection against these communicable diseases. M.M.R. (Measles, Mumps, Rubella) (two doses required for students born in 1957 or later) Dose 1 given at age months or later. #1 / / Dose 2 given at age 4-6 years or later, and at least one month after first dose. #2 / / Laboratory/serologic evidence of immunity (attach copy of titer and date). Tetanus-Diphtheria-Pertussis Tdap booster to be given within the last 10 years. / / Serogroup B Meningococcal Vaccine (MenB): (2-3 doses) Even if incomplete, provide dates of any doses. Dose #1: / / Dose #2: / / Dose #3: / /

6 Hepatitis A Immunization (hepatitis A) Dose #1: / / Dose #2: / / Immunization (Combined hepatitis A and B vaccine) Dose #1: / / Dose #2: / / Dose #3: / / Hepatitis B Three doses of vaccine or two doses of adult vaccine in adolescents years of age, or a positive hepatitis B surface antibody. Immunization (hepatitis B) Dose #1: / / Dose #2: / / Dose #3: / / Immunization (combined hepatitis A and B vaccine) Dose #1: / / Dose #2: / / Dose #3: / / Hepatitis B surface antibody Date: / / Result: Reactive Non-reactive Varicella Birth in the U.S. before 1980, a history of chicken pox, a positive varicella antibody, or two doses of vaccine. History of Disease Yes No or Birth in U.S. before 1980 Yes No Varicella antibody / / Result: Reactive Non-reactive Immunization Dose #1: / / Dose #2: / / given at least 12 weeks after first dose ages 1-12 and at least 4 weeks after first dose if age 13 years or older. Polio Primary series, doses at least 28 days apart. Three primary series are acceptable. See ACIP website for details. PV alone (oral Sabin three doses: Dose #1: / / Dose #2: / / Dose #3: / / IPV/PV sequential: Dose #1: / / Dose #2: / / Dose #3: / / IVP alone (injected Salk four doses): Dose #1: / / Dose #2: / / Dose #3: / / Dose #4: / / Influenza Annual immunization recommended to avoid influenza complications in high-risk patients, to avoid disruption to academic activities, and to limit transmission to other individuals. Date / / / / / / / / HPV Quadrivalent Human Papillomavirus Vaccine Three doses of vaccine for college students years of age at 0, 2, and 6 month intervals. Immunization HPV: Dose #1: / / Dose #2: / / Dose #3: / / 10/2016

7 HEALTH HISTRY FRM Recommended, but not required Missouri Western State University Esry Student Health Center 4525 Downs Drive Blum 203 St Joseph, M (816) Fax (816) Date SEMESTER YU PLAN T ATTEND: Fall Spring Summer G-Number HAVE YU PREVIUSLY USED ESRY STUDENT HEALTH CENTER SERVICES? N YES SSN Last Name First Name MI Date of Birth Age M or F (Circle one) Address City State Zip ( ) ( ) Phone Cell Phone Country of birth Current Do you plan to live on campus? YES N Participate in MWSU athletics? N YES Which sport? HEALTH INSURANCE INFRMATIN (Circle one) Parent s Insurance Medicare Medicaid International Student Health Insurance None EMERGENCY CNTACT INFRMATIN _ Name Relationship _ Address City State Zip ( ) ( ) ( ) Home Phone Work Phone Cell Phone Primary Physician Address Phone Fax ALLERGY HISTRY List any drug allergies: Reaction: List any allergies to materials (such as latex) Reaction: List any food allergies: Reaction: List any allergies to insect bites: Reaction: Are you receiving allergy injections? ** Reaction: **NTE: If Esry Student Health Center is to administer your allergy vaccine, detailed instructions are required from your physician. Please contact the Health Center, , for a packet of information to take to your allergist. CURRENT MEDICATINS List any drugs, medications, birth control, vitamins, and dietary supplements you currently use: HSPITALIZATIN/SURGICAL HISTRY List any hospitalization and prior operations you have had, with dates (i.e. appendectomy, fracture): MENTAL HEALTH HISTRY Have you ever suffered from, been treated for, or hospitalized for the following? Y N EXPLANATIN Bipolar disorder Substance abuse (alcohol, drugs) Eating disorder (anorexia, bulimia) Depression, anxiety

8 PERSNAL HISTRY Indicate whether you have had any of the following medical issues Y N Have you had? Y N Have you had? Y N Have you had? Acne Hearing loss Ulcers Anemia/Sickle cell/ther Heart murmur/other heart problems ther: Asthma/Lung disease Hepatitis FEMALES NLY Bleeding problem High blood pressure Irregular periods Blood clots in legs or lungs High cholesterol Breast lump or cyst Broken bones Irritable bowel Abnormal pap smear Cancer Kidney infection, stones Frequent vaginal infections Cerebral Palsy Migraine headaches Bladder infections Chicken pox Mononucleosis Pregnancy Colitis, ulcerative/crohn s disease Pneumonia MALES NLY Concussion Rheumatic fever Testicular mass or lump Congenital defect Rheumatoid, other arthritis Bladder infection Diabetes Scoliosis Prostate infection Epilepsy, seizures Thyroid problems Breast mass or enlargement Hay fever Tuberculosis or positive PPD Steroid use Do you have a medical disability or physical limitation? Is there a loss or serious impaired function of any of your organs? FAMILY HISTRY Has any family member in the last two generations (siblings, parents, grandparents) had any of the following? If yes, who and when? Y N Has a family member had? Who? Y N Has a family member had? Who? Stroke, blood vessel disease Heart disease Cancer High blood pressure Diabetes Liver disease Depression, suicide Genetic disorders Alcoholism ther: Blood clots in legs, lungs ther: ADDITINAL INFRMATIN Is there anything about your physical, mental or emotional health that would be helpful to Student Health Services in providing you with medical care? READ, CHECK AND SIGN BELW I am aware that Esry Student Health Center charges for services. I accept personal responsibility for the payment of incurred charges that will be placed on my MWSU account in the business office if not paid by cash or check at time of service. I understand that I am responsible for filing outpatient charges with my private health insurance carrier and acknowledge that my responsibility to the University is unaffected by the existence of health insurance coverage. I understand that MWSU offers international student health insurance which is the only insurance accepted and filed at Esry Student Health Center. I have personally supplied the above information and attest that it is true and complete to the best of my knowledge. I understand that the information contained on this form and in my medical records is strictly confidential and will not be released to anyone other than my healthcare provider, without my written authorization unless required by law. If I should be ill or injured or otherwise unable to sign the appropriate medical release form, I give my permission to MWSU Esry Student Health Center to release information from my medical record to a physician, hospital, or other medical professional involved in providing me with emergency treatment and/or medical care. I authorize any medical treatment for myself that may be advised or recommended by the medical providers at MWSU Esry Student Health Center Signature of student Date Signature of legal guardian (If patient is under 18) Date 10/16

9 Student Immunization Waiver for Meningococcal Vaccination Esry Student Health Center Student Information Please Print Clearly Student Immunization Waiver for Meningococcal Vaccination Missouri law requires students living in campus housing facilities receive the Meningococcal Vaccination unless a religious exemption is signed or a medical exemption by a physician is provided. To qualify for this exemption, you are required to review the information on the reverse side and sign the waiver. Last Name: First Name: G#: G MWSU Cell/Home Phone ( ) - Student Date of Birth: Home Address: City/State/Zip Code:_ Religious Exemption After reading the provided information, I understand the risks of being exempted from the meningococcal vaccine. To be completed by student 18 years of age or older: I choose to exercise my right to an exemption from the meningococcal vaccine at this time, due to my religious beliefs. Signature of Student: Date: For students under the age of 18: As the parent or legal guardian, I choose to exercise our right to an exemption from the meningococcal vaccine at this time, due to our religious beliefs. Printed Name of Parent/Legal Guardian: Signature of Parent/Legal Guardian: Date: Medical Exemption The student has not received the meningococcal vaccine based on the conclusion the immunization would seriously endanger the student's health or life or the student has documentation of the disease or laboratory evidence of immunity to the disease. Printed Name of Physician: Signature of Physician: Date: Physician s Contact Information: Street Address: City/State/Zip Code: Phone Number: Comments: *A letter from the physician of the student with the information requested is an acceptable substitute for the medical exemption portion of this form

10 Return completed form to: Esry Student Health Center, 4525 Downs Drive, Blum Union 203, Saint Joseph, M Telephone: (816) Fax: (816) health@missouriwestern.edu Esry Student Health Center 4525 Downs Drive, Blum Union 203 Saint Joseph, M Telephone: (816) Fax: (816) health@missouriwestern.edu Important Information Missouri State Law Missouri State Law 754 section require all students who reside in on-campus housing at a public institution of higher education to have received the meningococcal vaccine unless a signed statement of medical or religious exemption is on file with the institution's administration. A medical exemption requires a signed certification by a physician licensed to practice in Missouri indicating that the immunization would seriously endanger the student's health or life or the student has documentation of the disease or laboratory evidence of immunity to the disease (see form on reverse). A religious exemption requires a statement in writing to the institution's administration that the immunization violates his/her religious beliefs (see form on reverse). Important Information Facts about Meningococcal Disease What Is Meningococcal Disease? Meningococcal disease refers to any illness that is caused by Neisseria meningitidis, also known as meningococcus bacteria. The two most severe and common illnesses caused by meningococcus bacteria include meningitis (an infection of the fluid and lining around the brain and spinal cord) and septicemia (a bloodstream infection). Bacterial meningitis is very serious and can be deadly. Death can occur in as little as a few hours. While most people with meningitis recover, permanent disabilities such as brain damage, hearing loss, and learning disabilities can result from the infection. How Is Meningococcal Disease Spread? The bacteria that cause meningococcal disease are spread from person to person by sharing respiratory secretions (such as saliva, by kissing or coughing) during close or lengthy contact, especially among people who share a room or live in the same household. Although anyone can get meningococcal disease, teens and college students living in residence halls, are at an increased risk for meningococcal disease compared with other persons of the same age. Where can I get more information on the types of meningococcal vaccines, risk factors, and potential reactions to the vaccine? 1. Contact your healthcare provider. 2. Contact the Esry Student Health Center (816) Contact your local or state health department. 4. Contact the Centers for Disease Control and Prevention (CDC) or visit Does the Esry Student Health Center offer the meningococcal vaccination? Yes, the Esry Student Health Center does offer the meningitis vaccine. If you would like to schedule an appointment, please call (816) or stop by the Health Center located in the Blum Student Union, Room 203. Walk-ins are welcome, however appointments are preferred. 10/2016