Connecticut State University Student Health Services Form Instructions

Similar documents
Student Wellness Services-Health

Student Health Services 881 Commonwealth Ave, West / Student Information (To be completed by the student) Student Name Last First Middle

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

Student Health Information

IMMUNIZATION & PHYSICAL FORM

Immunization Requirements

DEADLINE To return completed form: Within 30 days of registering for classes

IMMUNIZATION & PHYSICAL FORM

MUSC Student Pre-Matriculation Requirements Instructions for Completion of Form

Signature of student Date Signature of parent or guardian (if student is a minor) Date

Report of Medical History

Immunization Policy & Forms. 33 Prospect Hill Road Cromwell, Connecticut / Tel. (860) Fax: (860) /

IMMUNIZATION & PHYSICAL FORM

STUDENT HEALTH SERVICES IMMUNIZATION FORM FOR GUILFORD COLLEGE 5800 West Friendly Avenue Greensboro, NC 27410

Dear Student, Welcome to the University of Chicago!

Name: New York Medical College A MEMBER OF THE TOURO COLLEGE AND UNIVERSITY SYSTEM. HEALTH SERVICES HISTORY and PHYSICAL

Healthcare Requirements for Health Science Students To Be Completed by your Primary Healthcare Provider

Student Health and Immunization Record

Hospital-based Massage Training Program Admissions Check List

STUDENT MEDICAL FORM

Vassar College 124 Raymond Avenue Box 17 Poughkeepsie New York Please contact us at for any questions/concerns.

Keiser University Health Forms. Student Name: D.O.B. / /

Student Health Services

SHENANDOAH UNIVERSITY HEALTH FORM

Special Category Volunteer Medical Packet

Student Health Services 100 East Brown Street (Phone)

IMMUNIZATION AND MEDICAL HISTORY FORM

Summary of Immunization Options

Student Health Record

Name Age Birthday / / Sex Last First MI. Home Address Street Apt City State Zip Code Home phone: ( ) Cell phone: ( ) Name of parent(s) or guardian:

SUMMER HEALTH PROFESSIONS EDUCATION PROGRAM FOR ACCEPTED STUDENTS

* Health Insurance Verification Form, submitted on line. Click on link. Mandatory Health Insurance Verification Form

EMS Education. Immunization/Physical Policy 2016

FULL-TIME ADULT STUDENT Acceptance Package Phase II

Fax MUSC Student. standards is done. to protect the. 1. and both. may. is non immune

WELLNESS CENTER Student Health Services (434) FAX (434)

Date of Birth Soc. Sec. or UD ID # Month Day Year. Country of Birth If not USA, indicate when you entered this country M/Y

Physician Assistant Program Required Immunization Form

Radford University School of Nursing GRADUATE HEALTH RECORD FORM

N E W Y O R K M E D I C A L C O L L E G E A M E M B E R O F T H E T O U R O C O L L E G E A N D U N I V E R I S T Y S Y S T E M

HEALTH OFFICE, Poughkeepsie, NY Residential Student:

Clarkson University Summer Camp Health Packet 2017 Camp(s) Attending: Dates:

SPOKANE COMMUNITY COLLEGE HEALTH SCIENCE PROGRAMS 1810 N GREENE STREET, MS 2090 SPOKANE WA PHYSICAL EXAMINATION (Student completes this side)

Dear New WUSM Student:

Student Health Record

Wisconsin Indianhead Technical College Allied Health and Nursing Divisions Health Form

Doctor of Pharmacy Program Required Immunization Form

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS

SCHOOL OF MEDICINE IMMUNIZATION COMPLIANCE FORM

IMMUNIZATION & PHYSICAL FORM CELOP

Name: RUID: Last, First MI This section is to be completed by the students' licensed healthcare provider. VACCINE Dose #1 Date

Student Health Medical Forms

Langston University Student Health Services Policies and Forms October 3, 2016

PRE-ADMISSION HEALTH CHECKLIST

THURGOOD MARSHALL ACADEMY PCHS ATHLETIC INFORMATION PACKET SY

IMMUNIZATION REQUIREMENTS FORM

Part I: Health Form. This form is to be completed by the incoming student by July 15. Name: Date of Birth:

Pre-Matriculation Physical Evaluation Form for Category A

Vice Chancellor, Health Affairs & Dean, School of Medicine Vice Chancellor & Dean s Office Origination Date: 05/20/2013 Date of Revision: Scope:

TO BE COMPLETED BY APPLICANT. Name: Age: Birth Date: (First) (M.I.) (Last) Home Address: (Number and Street) (City) (State) (Zip) Address:

New Student Health Form

Michael G. DeGroote School of Medicine Visiting Student Electives Program Health Screening Record

DO NOT SEPARATE THESE FORMS

Health Card #: Expiry date: Province: Address (during academic program): Apt. #: City: Province: Country: Postal/Zip Code: Address: Apt.

Student Health Services Office 5400 Ramsey Street Fayetteville, North Carolina Phone: (910) or (910) FAX: (910)

STUDENT HEALTH SERVICES 204 College Rd, Hampden-Sydney, VA 23943

THIS FORM IS FOR MEDICAL STUDENTS ONLY IMMUNIZATION RECORD

Certificate of Health Examination and Immunity

Rutgers School of Nursing Center for Professional Development 65 Bergen Street, Room Newark, New Jersey 07107

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

Your completed Health Record and any laboratory results must be uploaded to the Student Health Portal at: shac.usciences.edu

Juntendo University Hospital Immunization Requirements

Dear Incoming Student:

Vulnerable Sector Police

Student Health Center Phone: Fax:

Required Health Records for all Students

PRE-CLINICAL HEALTH REQUIREMENTS (PCHR)-Freshman,Transfer, 2nd Degree Nursing

Immunization Packet for Incoming Students

Information Regarding Immunizations

Preadmission Health History and P hysical for NOVA Nursing Programs

Personal Information Name Campus Housing Resident Commuter Student ID Number Date of Birth Sex

Required Medical Forms

Vulnerable Sector Police

Holy Family University, Student Health Services, Directions for Completion of Health Packet

St Christopher Iba Mar Diop College of Medicine

Immunization and TB screening instructions Executive MBA/MS in Healthcare Leadership

CNHP IMMUNIZATION RECORD (7 TOTAL PAGES) MENINGOCOCCAL FORM

CERTIFICATE OF IMMUNITY

Program or Major Code: Current address: Blazer ID: Local Address: Permanent Address

HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES

Dear Roanoke College Student:

EMT-Intermediate Certification Class Requirements

FULL DAY Application Checklist

UNIVERSITY OF WISCONSIN-MADISON SCHOOL OF PHARMACY. Health Policies

Explanation of requirements for clinical experiences HFU

WHEATON COLLEGE STUDENT HEALTH SERVICES MEDICAL FORMS

HUMBER COLLEGE & UNIVERSITY OF GUELPH-HUMBER

Advanced EMT (AEMT) Program Application

NOSM Learner Immunization Form

Transcription:

Connecticut State University Student Health Services Form Instructions Important: Prior to submitting your information, please make a copy for your records Connecticut General Statute and CCSU requires the following information for all matriculated students (full and part time). Please submit this form to Student Wellness Services- no later than July 15 for the Fall semester and December 15 for the Spring semester. Failure to submit the required form will result in a health hold on your student account. Proof of immunity to Measles (Rubeola): you must provide proof of one of the following: Two measles or two MMR immunizations (1 st dose on or after your 1st birthday; second dose at least 28 days later); OR Lab results showing a positive measles titer (blood test) Please submit a copy of the test results with health form. Proof of immunity to Rubella: you must provide proof of one of the following: Two rubella or two MMR immunizations (1 st dose on or after your 1st birthday; second dose at least 28 days later); OR Lab results showing a positive rubella titer (blood test) Please submit a copy of the test results with health form. Proof of immunity to Mumps: you must provide proof of one of the following: Two mumps or two MMR immunizations (1 st dose on or after your 1st birthday; second dose at least 28 days later); OR Lab results showing a positive mumps titer (blood work) Please submit copy of the test results with health form. Proof of immunity to Varicella (chicken pox): you must provide proof of one of the following: Two varicella immunizations (second dose at least 28 days after the first dose); OR Lab results showing a positive varicella titer (blood test) Please submit copy of the test results with health form. Certification of confirmed cases of measles, mumps, rubella & varicella by a licensed health care provider may be submitted in lieu of the above. (signed note from a medical provider). Proof of Meningococcal vaccination (Menactra) is required for all residential students prior to room assignment. No student may move into campus housing without proof of this vaccine. The vaccine must have been administered within five years before enrollment. Hepatitis B: The American College Health Association, the Connecticut Public Health Department, and the Centers for Disease Control recommend students be immunized against Hepatitis B (while not required it is strongly recommended). Tetanus: A booster shot is recommended every ten years. IMMUNIZATION EXEMPTIONS Students born prior to January 1, 1957 are exempt by age from the measles, mumps, and rubella requirement. Students born prior to January 1, 1980 are exempt by age from the varicella requirement. Vaccination waivers for religious or medical reasons are acceptable and can be found at www.ccsu.edu/healthservice/forms. Exemptions for either medical or religious reasons subjects the individual to exclusion from campus in the event of an outbreak of a disease for which immunizations are required. Please check your Central Pipeline account no sooner than 3 business days after submitting the required information. Your Central Pipeline account will indicate the MISSING information under the Registration Status Section. If you have a health hold and nothing is indicated as to what is missing, we have not received ANY information for you. You may mail, fax, drop off (page 2 of form) or email to sws@ccsu.edu. Please only submit ONE copy of your form to avoid processing delays. Thank you. Reminder: Prior to submitting your information, please make a copy for your records

Connecticut State University Student Health Services Form Semester Beginning School Fall Spring of PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS Last Name First Name MI FOR OFFICE USE ONLY Complete Missing: BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED of Birth and Birthplace: Sex/Gender: Student ID #: State of Connecticut and Connecticut State Universities REQUIRE: Two doses for each Measles, Mumps, Rubella & Varicella One dose of Meningitis* Complete TB Risk and/or Test or Treatment Vaccine & Given OR Incidence of OR Requirements Disease Titer Test Results (attach lab report) 1 Measles #1 or MMR Measles Titer : Measles #2 or MMR 2 Mumps #1 or MMR Mumps Titer Mumps #2 or MMR 3 Rubella #1 or MMR Rubella Titer Rubella #2 or MMR 4 Varicella #1 OR Incidence of OR Varicella Titer Varicella is required only for students born on or after January 1, 1980 Chicken Pox Disease #1 Must be on or after 1 st birthday; Varicella #2 #2 Must be at least 28 days after 1 st immunization Provider Initials: 5 Meningococcal (must include groups A, C, Y&W-135) If living on-campus, your most recent vaccination must be within 5 years of your 1 st day of classes at the University. Please note: You will not be permitted to move in to campus housing without first providing the Student Health Service with this information. (s):1. 2. Brand of Vaccine: I will not be living on-campus. I do not require this vaccine. 6 TUBERCULOSIS (TB) RISK QUESTIONNAIRE - A through D To be answered by the Student A. Have you ever had a positive tuberculosis skin or blood test in the past? If you answer, Yes, Section 6b., CHEST X-RAY, must be completed Yes No B. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)? Yes No C. Were you born in one of the countries listed below? If yes circle country Yes No D. Have you traveled or lived for more than one month in one or more of the countries listed below? If yes circle country. Yes No Afghanistan,Algeria,Angola,Anguilla,Argentina,Armenia,Azerbaijan,Bahrain,Bangladesh,Belarus,Belize,Benin,Bhutan,Bolivia,Bosnia&Herzegovina,Botswana,Brazil,Brunei,Darussalam,Bulgaria,BurkinaFaso,Burundi,Cambodia,Camer oon,capeverde,centralafricanrepublic,chad,china,china:hongkongspecialadministrativeregion,china:macaospecialadministrativeregion,colombia,comoros,congo,côte d'ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo,Djibouti,DominicanRepublic,Ecuador,ElSalvador,EquatorialGuinea,Eritrea,Estonia,Ethiopia,Fiji,FrenchPolynesia,Gabon,Gambia,Georgia,Ghana,Guam,Guatemala,Guinea,Guinea- Bissau,Guyana,Haiti,Honduras,India,Indonesia,Iraq,Iran,Japan,Kazakhstan,Kenya,Kiribati,Kuwait,Kyrgyzstan,LaoPeople'sDemocratic,Republic,Latvia,Lesotho,Liberia,Libyan,Arab,Jamahiriya,Lithuania,Madagascar,Malawi, Malaysia, Maldives, Mali, Marshall Islands,Mauritania,Mauritius,Mexico,Micronesia(FederatedStates),Mongolia,Morocco,Mozambique,Myanmar(Burma),Namibia,Nauru,Niue,Nepal,Netherlands,Antilles,NewCaledonia, Nicaragua,Niger,Nigeria,NorthernMarianaIslands,Pakistan,Palau,Panama,Papua,NewGuinea,Paraguay,Peru,Philippines,Poland,Portugal,Qatar,Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, Saint Vincent and the Grenadines, Sao Tome and Principe,Senegal,Serbia,Seychelles,SierraLeone,Singapore,SolomonIslands,Somalia,SouthAfrica,SouthSudan,SriLanka,Sudan,Suriname,Swaziland,Syrian,ArabRepublic,Tajikistan, Taiwan, Thailand, The former Yugoslav Republic of Macedonia,TimorLeste,Togo,Trinidad&Tobago,Turks&Caicos,Tunisia,Turkey,Turkmenistan,Tuvalu,Uganda,Ukraine,United Republic of Tanzania, Uruguay, Uzbekistan, Vanuatu, Venezuela(Bolivarian Republic),Viet Nam, Wallis and Futuna Islands, Yemen, Zambia,Zimbabwe Based on WHO Global TB Report 2013 6. Prior BCG does not exempt patient from this requirement. If you answer NO to all questions no further action is required. If you answer YES to B-D of the above questions, Connecticut State University requires that a healthcare provider complete the following TB testing evaluation. 6a. TB BLOOD TEST OR Interferon-gamma release assay Result: NEG POS 6a. TB SKIN TEST Use 5TU Mantoux test only. 6b. CHEST X-RAY Required within the past 12 months for a previous or current positive TB skin or blood test. Copy of X-ray report MUST be attached. X-ray is not needed if asymptomatic AND completed full course of treatment for the positive TB test (latent TB). Planted: Read: Interpretation (If no induration, mark 0) NEG POS mm of induration Chest X-ray Result: Normal Abnormal (Attach copy of report) 6c. TB TREATMENT MEDICATION (with dose): Frequency: Start & Completion s: Other Vaccination History (Tetanus Booster within last 10 years and Hepatitis B series are recommended if not already completed) Hepatitis B #1 Hepatitis B #2 Hepatitis B #3 Hepatitis Titer Result: POS NEG Last Tetanus Booster: Td or Tdap Other Vaccination: Other Vaccination: Other Vaccination: Signatures I confirm that the information above is accurate. Clinician Signature: Student consent for treatment required to be signed (If you are less than 18 years of age signatures of both the student and one parent/guardian are required) I hereby grant permission for the Connecticut State staff to provide me with appropriate medical and mental health treatment including medications for treatment of illnesses/injuries and to arrange for any emergency medical care if circumstances at that time make it impossible for me to make such decisions. Furthermore, I understand that University Health Services staff may disclose my student medical records and/or information from such records to appropriate University personnel and/or Emergency Contacts identified within my records in the event of a health or safety situation as determined by the Student Health Services staff. Signature of Student Signature of Parent/Guardian

Connecticut State University Student Health Services Form Page 2 PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED Student Name Home/Personal Email Address Student Cell Phone Permanent Home Information Notify in Case of Emergency Home Phone Cell/Work Phone Name Relationship Street Address Home Phone Cell/Work Phone City State Zip Street Address Name: Personal Physician/Healthcare Provider City State Zip Address: Telephone #: FAX # Personal Medical History- Please circle all below that apply to you. Check here if none apply Alcohol/Substance Abuse Dental Problems Mononucleosis Anemia Diabetes Mumps Anxiety/Depression/Mental illness Gastrointestinal Conditions/IBS Rheumatic Fever Asthma Gynecological Conditions Seizures Cancer Hepatitis B or C Disease Sickle Cell Disease Cardiac Condition/Heart Murmur High Blood Pressure Thyroid Disorder Coagulation/Bleeding Disorder HIV/AIDS Tuberculosis Concussion Measles Other please explain Allergies: Drugs & Other Severe Adverse Reactions - Please complete all that apply and explain reaction. Check here if you have no allergies Medication Food Insect Seasonal Environmental X-ray Contrast Are any life threatening? Yes No Do you carry an Epi Pen? Yes No Prior Hospitalizations or Surgeries - Please list dates and reasons. Medications Frequent or regular- Please list all prescriptions, natural and over the counter medications. Is there any other medical information or health concern that we should know about? Please attach any additional information to further explain your condition(s) or concern(s). Current Height**: Current Weight**: Last Blood Pressure (if known)**: **not required Did you sign the Consent for Treatment on Page 1? Did you make a copy for your records prior to submitting? Please return by mail or fax to the appropriate Health Service listed below. You may also email to sws@ccsu.edu. Please send ONE copy only to avoid a delay. Central Connecticut State University 1615 Stanley Street New Britain, CT 06050 860/832-1925 Fax 860/832-2579 Eastern Connecticut State University 185 Birch Street Willimantic, CT 06226 860/465-5263 Fax 860/465-4560 Southern Connecticut State University 501 Crescent Street New Haven, CT 06515 203/392-6300 Fax 203/392-6301 Western Connecticut State University 181White Street Danbury, CT 06810 203/837-8594

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback