Incoming Student Immunization Information Primary Care Health Service

Transcription

Incoming Student Immunization Information Primary Care Health Service
Primary Care Health Service
Incoming Student Immunization Information
PRIMARY CARE HEALTH SERVICE
LOWER LEVEL – BROOKS HALL
3009 BROADWAY, NEW YORK, NY 10027
PHONE: 212.854.2091 FAX: 212.854.2702
For questions please email
Stephanie Paciulla at [email protected]
THESE FORMS MUST BE SUBMITTED BY
JUNE 30, 2012
REQUIRED VACCINATIONS PRIOR TO ARRIVAL AT BARNARD
The vaccinations and/or proofs of immunity for MMR and the completion of the Meningitis
Response form are required by New York State Public Health Laws 2165 and 2167. No student
will be permitted on campus, or to attend the institution, without compliance. Please print out the
next several pages, bring them to your health care provider to document your immunity from
measles, mumps and rubella. If you have had a meningococcal meningitis vaccination, you will
need to provide relevant documentation.
Please have all dates in the mm/dd/yyyy format
Part I:
Date _________________
Birth Date ___________________
Name
Last
First
M
Address
City, State, Zip
Part II: - TO BE COMPLETED & SIGNED BY YOUR HEALTH CARE PROVIDER.
All information must be in English.
A. M.M.R. (Measles, Mumps, Rubella) (Two doses or titers mandated by NYS law)
1. Dose 1 Must have been given no earlier than 4 days before 1st birthday
(Date:)
2. Dose 2 given at age 4-6 years or later but not less than 28 days after first dose
(Date:)
(Please complete only if applicable)
Result: Positive Negative
3. Date of Measles Titer
Date of Mumps Titer _________________________ Result: Positive Negative
Result: Positive Negative
Date of Rubella Titer
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B. TUBERCULOSIS SCREENING: Please answer the following questions:
1. Have you ever had a positive TB skin test? Yes
No
2. Have you ever had close contact with anyone who was sick with TB? Yes
No
3. Were you born in one of the countries listed below and arrived in the U.S. within the
past 5 years? (If yes, please CIRCLE the country) Yes No
4. Have you ever traveled (for at least one month)* to/in one or more of the countries
listed below? (If yes, please CIRCLE the country/ies) Yes No
* The significance of the travel exposure should be discussed with a health care provider and evaluated
Afghanistan
Algeria
Angola
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia (Plurinational
State of)
Bosnia and
Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African
Republic
Chad
China
Colombia
Comoros
Congo
Cook Islands
Côte d'Ivoire
Croatia
Democratic People's
Republic of Korea
Democratic Republic
of the Congo
Djibouti
Dominican Republic
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
French Polynesia
Gabon
Gambia
Georgia
Ghana
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iraq
Japan
Kazakhsta
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
Micronesia
(Federated States
of)
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nepal
Nicaragu
Niger
Nigeria
Pakistan
Palau
Panama
Papua New Guinea
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
Sierra Leone
Singapore
Solomon Islands
Somalia
South Africa
Sri Lanka
Sudan
Suriname
Swaziland
Syrian Arab Republic
Tajikistan
Thailand
The former Yugoslav
Republic
of Macedonia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Republic of
Tanzania
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian
Republic of)
Viet Nam
Yemen
Zambia
Zimbabwe
Source: W orld Health Organization Global Health Observatory Tuberculosis Incidence 2009. Countries with incidence rates of ≥ 20 cases per
100,000 population. For future updates, refer to http://apps.who.int/ghodata/?vid=510
If the answer is YES to any of the above questions, Barnard College requires a PPD or Mantoux test.
A chest x-ray is required if the tuberculin skin test is positive.
Date PPD Test Administered:_________________ Date PPD Test Read:_________________
Result: Positive Negative AND _________mm induration
Date of Chest X-ray: __________________
Result: Normal Abnormal
If the answer to all of the above questions is NO, no further testing or further action is required.
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Primary Care Health Service
RECOMMENDED VACCINATIONS PRIOR TO ARRIVAL AT BARNARD
C. HEPATITIS A
Dose#1
or
Hepatitis A Titer: Date_
HEPATITIS B
Dose#1_
_Dose#2
Result Positive Negative
Dose#2
Dose#3
_Result Positive  Negative
Hepatitis B Titer: Date_
D. VARICELLA (CHICKEN POX)
Dose#1__________________Dose#2__________________
or
Varicella Titer: Date_
Result Positive Negative
If you had the disease, when did you have it? ______________________
or
E. TETANUS-DIPHTHERIA-PERTUSIS (Primary series with DTaP or DTP and booster with Td
in the last ten years meets requirement. )
Primary series of four doses with DTaP or DTP:
Completed Basic Series:  Yes No
Tdap (date of most recent booster)
F. POLIO (Primary series in childhood meets requirement; three primary series schedules are
acceptable)
Completed Basic Series? Yes No
Last Polio Booster date_
G. HPV VACCINE (dates for each one)
#1
#2
#3
HEALTH CARE PROVIDER’S INFORMATION: (Please note that the only acceptable signatures are that of
a physician, physician assistant or nurse practitioner.)
___________________________
Provider’s Name
__________________________________________
Provider’s Signature
Place Provider Stamp Here
____________________________________________________
Provider’s Address
____________________________________________________
Provider’s Telephone and Fax Numbers
______________________
Date
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