Ri Refugee Health Screening Form - Department Of Health
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1
2R.I. Refugee Health
Provider Information
Physician’s Name:
Screening Form
Facility:
Please complete health screening within 30 days of U.S. arrival.
Upon completion, mail or fax to:
Refugee Health Program
Address:
Rhode Island Department of Health
3 Capitol Hill, Room 407
Phone:
Providence, RI 02908
Phone: (401) 222-2901 Fax: (401) 273-4350
Patient Information
Unique ID:
Last Name:
Street Address:
Date of U.S. Arrival:
First Name:
Country of Origin:
Middle Name:
Country of Exit:
Gender:
M
F
City:
Language Spoken:
DOB:
County, Zip:
Language Read:
Parent/Guardian:
Phone:
Interpreter Provided:
Y
N
Ethnicity:
Hispanic
Non-Hispanic
Race:
White
Asian
Native Hawaiian/ Pacific Islander
African American/Black
American Indian/Alaskan Native
Volag (check resettlement agency):
International Institute of RI
Jewish Family Service
Diocese of Providence
Immunization Record: Review overseas medical exam (DS-2053) if available and document immunization dates.
For measles, mumps, rubella, and varicella: indicate if there is lab evidence of immunity; if so, immunizations are not
needed against that particular disease. For all other immunizations, update series, or begin primary series if no
immunization dates are found. All vaccines may be given at the same time in different sites of the body.
No immunization
Immunizations
Immunization Dates
needed if lab
evidence of
mm/dd/yy
mm/dd/yy
mm/dd/yy
mm/dd/yy
mm/dd/yy
mm/dd/yy
immunity or history
of disease
Measles
Mumps
Rubella
Varicella (VZV)
Diphtheria/Tetanus/Pertussis
(DtaP/DTP/DT)
Tetanus-Diphtheria (Td)
Polio (IPV, OPV)
Hepatitis B
Haemophilus influenzae
type b (Hib)
Hepatitis A
Influenza
Pneumococcal
Other
Tuberculosis Screening
PPD/Mantoux Regardless of BCG Hx
CXR (if indicated)
TB Therapy (if indicated)
Date planted
Date
Referred for treatment of suspect or
active TB to ________ (reportable)
Date read
Findings
Referred for LTBI treatment to ______
PPD size (mm)
To treat for LTBI on site
PPD interpretation
Pos
Neg
No referral for LTBI treatment:
Hx of BCG?
Y
N
U
Treated overseas
Refused
Date of BCG
Pregnancy
Other:
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