Directions For The Medical Form - Auburn University Medical Clinic printable pdf download

Directions For The Medical Form - Auburn University Medical Clinic

DIRECTIONS FOR THE MEDICAL FORM

Both pages must be completely filled out.

1. Fill out the form COMPLETELY before turning it in or it will be returned to you.

WARNING: An incomplete form may keep students from registering for classes.

2. You MUST put the student’s complete social security number on the form.

3. The State of Alabama and Auburn University REQUIRE two immunizations/tests:

**Note: we do not require a physical**

TUBERCULIN SKIN TEST (PPD)

MEASLES (MMR)

4. The doctor MUST sign and print his/her name OR a clinic stamp MUST be present for the

immunizations/tests. Attaching a copy of the immunization/test records with a doctor’s

signature or clinic stamp is acceptable.

5. A copy of the insurance card (front & back) should be included. The date-of-birth of the

policy holder is REQUIRED. Without this information claims will not be processed.

THE STUDENT MUST SIGN THE BOTTOM OF PAGE 2. FORM WILL BE CONSIDERED

INVALID IF LACKING STUDENT SIGNATURE.

Forms may be FAXED, MAILED, scanned and E-MAILED, or HAND DELIVERED. All

submission information is listed at the top of Page 1.

Appendix A

Positive (+) PPD

If the student has tested positive for the TB Skin test in the past or currently tests positive, the

requirements for further testing are below.

Chest X-Ray

T-Spot

Scenarios

Required

Patient has been treated and has taken INH (isoniazid), RIF (rifampin), EMB



(ethambutol), or PZA (pyrazinamide) medication for 6-9 months following the positive

(+) PPD. Please attach documentation of medication treatment to this form



Patient has NOT taken INH, RIF, EMB, nor PZA medication

Patient has not taken INH, RIF, EMB nor PZA medication and a T-spot resulted

N/A

negative (-) within six (6) months prior to the first day of class. Please attach

documentation of the T-spot results with this form

Patient has not taken INH, RIF, EMB nor PZA medication and a T-Spot resulted

positive (+) within six (6) months prior to the first day of class. Patient has latent or



active Tuberculosis. Patient requires treatment. Please attach documentation of the T-

spot result with this form

Directions For The Medical Form - Auburn University Medical Clinic