Connecticut State University Student Health Services Form Page 3
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4Connecticut State University Student Health Services Form
FOR OFFICE USE ONLY
Complete Missing: _______________________
Date Beginning School
Fall
Spring of __________
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Last Name
First Name
MI
#:
Student ID
Date of Birth and Birthplace:
Sex/Gender:
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
OR
OR
Titer Test Results
Requirements
Vaccine & Date Given
Incidence of
(attach lab report)
Disease
st
1
Measles #1
or
MMR
Date:
Measles Titer
Must be on or after 1
birthday.
Date
Date :
st
Measles #2
or
MMR
Must be at least 28 days after 1
immunization.
Date:
Result
Pos
Neg
st
2
Mumps #1
or
MMR
Date
Mumps Titer
Must be on or after 1
birthday.
Date:
Date:
st
Mumps #2
or
MMR
Must be at least 28 days after 1
immunization.
Result
Pos
Neg
Date:
st
Rubella #1
MMR
Must be on or after 1
birthday.
3
or
Date
Rubella Titer
Date:
Date:
st
Rubella #2
or
MMR
Must be at least 28 days after 1
immunization.
Result
Pos
Neg
Date:
4
OR
OR
Varicella Titer
Varicella is required only for students born on or after January 1, 1980
Varicella #1
Incidence of
st
Date:
#1 Must be on or after 1
birthday;
Date:
Disease Chicken Pox
st
#2 Must be at least 28 days after 1
immunization
Varicella #2
Date:
Result
Pos
Neg
Date:
Provider Initials:
st
5
If living on-campus, your last vaccination must be within 5 years of your 1
day of school.
Meningococcal
(must include groups A,C,Y&W-135)
Date(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
6b
Yes
No
A. Have you ever had a positive tuberculosis skin or blood test in the past?
If you answer, “Yes,” Section
., “CHEST X-RAY”, must be completed
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,(Plurinational,State,of),Bosnia,and,Herzegovina,Botswana,Brazil,Brunei,Darussalam,Bulgaria,BurkinaFaso,
Burundi,Cambodia,Cameroon,Cape,Verde,Central,African,Republic,Chad,China,China,Hong,Kong,Special,Administrative,Region,China,Macao,Special,Administrative,Region,Colombia,Comoros,Congo,Côte,d'Ivoire,Democratic,Peop
le's,Republic,of,Korea,Democratic,Republic,of,the,Congo,Djibouti,Dominican,Republic,Ecuador,El,Salvador,Equatorial,Guinea,Eritrea,Estonia,Ethiopia,Fiji,French,Polynesia,Gabon,Gambia,Georgia,Ghana,Guam,Guatemala,Guinea,G
uinea-Bissau,Guyana,Haiti,Honduras,India,Indonesia,Iraq,Iran,Japan,Kazakhstan,Kenya,Kiribati,Kuwait,Kyrgyzstan,Lao,People's,Democratic,Republic,Latvia,Lesotho,Liberia,Libyan,Arab,Jamahiriya,Lithuania,Madagascar,Malawi,
Malaysia,Maldives,Mali,Marshall,Islands,Mauritania,Mauritius,Mexico,Micronesia,(Federated,States,of),Mongolia,Morocco,Mozambique,Myanmar,(Burma),Namibia,Nauru,Niue,Nepal,Netherlands,Antilles,New,Caledonia,Nicarag
ua,Niger,Nigeria,Northern,Mariana,Islands,Pakistan,Palau,Panama,Papua,New,Guinea,Paraguay,Peru,Philippines,Poland,Portugal,Qatar,Republic,of,Korea,Republic,of,Moldova,Romania,Russian,Federation,Rwanda,Saint,Vincent,a
nd,the,Grenadines,Sao,Tome,and,Principe,Senegal,Serbia,Seychelles,Sierra,Leone,Singapore,Solomon,Islands,Somalia,South,Africa,South,Sudan,Sri,Lanka,Sudan,Suriname,Swaziland,Syrian,Arab,Republic,Tajikistan,Taiwan,Thailan
d,The,former,Yugoslav,Republic,of,Macedonia,TimorLeste,Togo,Trinidad,and,Tobago,Turks,and,Caicos,Islands,Tunisia,Turkey,Turkmenistan,Tuvalu,Uganda,Ukraine,United,Republic,of,Tanzania,Uruguay,Uzbekistan,Vanuatu,Venez
uela,(Bolivarian,Republic,of),Viet,Nam,Wallis,and,Futuna,Islands,Yemen,Zambia,Zimbabwe Based on WHO Global TB Report 2013
6.
IF you answer
NO
to all questions no further action is required.
Prior BCG does not exempt patient from this requirement.
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 and x-ray
within 6 months prior to the start of classes.
(After February for Fall Semester and after July for Spring Semester.)
OR
6a. TB SKIN TEST
6b. CHEST X-RAY
6c. TB TREATMENT
6a. TB BLOOD TEST
Use 5TU Mantoux test only.
Required within 1 year
for past or current positive TB skin or blood
MEDICATION (with dose):
Interferon-gamma
test. X-ray report MUST BE ATTACHED
release assay
Date
Interpretation (
If no induration, mark 0)
Date:
Chest X-ray Date:
Frequency:
Planted:
NEG
POS
Start & Completion Dates:
Date
Result:
NEG
POS
_______mm of induration
Normal
Abnormal
Read:
Other Vaccination History (Tetanus Booster within last 10 years and Hepatitis B series are recommended)
Hepatitis B #1
Hepatitis B #2
Hepatitis B #3
Hepatitis Titer
Result:
Date
Date
Date
Date
POS
NEG
Last Tetanus Booster: Td
or Tdap
Other Vaccination:
Other Vaccination:
Other Vaccination:
Date:
Signatures
I confirm that the information above is accurate.
Clinician Signature:
Date:
Physical Examination Affirmation:
I have examined this patient on _________________ and find no medical condition that would prohibit
him/her from participating fully in all activities including physical education, trying out for competitive sports or military training and employment.
:
Clinician Signature
Date:
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 University Health Services 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
Date:
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