Dear Incoming Student, On behalf of the staff of - RISD Pre

Dear Incoming Student,
On behalf of the staff of the RISD Health Services, I would like to extend to you a warm welcome to the RISD PreCollege program.
In order to provide you with the best care while you are at RISD, we require the completion of all health forms
st
by May 1 .
Please use this checklist to assure all required documentation has been completed and submitted by the
st
May 1 deadline.
☐ Submit the Physical Examination Form – REQUIRES PHYSICIAN SIGNATURE
And Vaccinations required by Rhode Island state law:
☐ 1 Tdap booster (within the last 10 years)
☐ 2 MMR (Measles, Mumps, Rubella)
☐ 3 Hepatitis B (series can be started and then 2nd dose will be due 1 month from 1st dose)
☐ 2 Varicella (Chicken Pox) or proof of disease by age/date
☐ Submit the Tuberculosis (TB) Risk Factor Screening - REQUIRES PHYSICIAN SIGNATURE
☐ Submit the Personal Health History Form – REQUIRES PARENT OR GUARDIAN SIGNATURE
☐
☐
(if student is under 18)
Submit the Parental Permission / Emergency Contact Form – REQUIRES PARENT OR
GUARDIAN SIGNATURE (if student is under 18)
Submit the Health Insurance Policy Information (compulsory for all students attending
classes for more than 2 weeks)
☐ Submit the Student General Information Form
☐ Read the downloaded Meningococcal Disease Information Sheet
☐ Read the downloaded RISD Immunization Fact Sheet
Please be aware that your registration is not considered complete until your completed and signed Health
Form has been received by Health Services.
**Students without completed and signed Health Forms, on file with Health Services will not be able
to receive their course schedule and begin attending classes. This may result in dismissal from the
Pre-College program.
Please keep a copy for your records and return completed forms by scan/email fax or snail mail to:
RISD Health Services
Two College Street
Providence, RI 02903
Fax: (401) 454-6628
Email: [email protected]
We appreciate your cooperation in returning these forms by the deadline and look forward to your arrival on campus.
Sincerely,
RISD Health Services
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Physician’s Form - Signature Required – Return Forms To:
RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
PHYSICAL EXAMINATION FORM
To the examining Physician: Please review the student’s history and complete this form. Please comment on all positive answers.
This student has been accepted and the information supplied will not affect his/her status. It will be used for continuity of care.
/
Last name
First
BP
Pulse
Height
Weight
BMI
Middle initial
/
Date of birth
Urinalysis:
Sugar
Albumin
Micro.
Hematocrit
Gender
Last Menstrual Period
Corrected Vision R
ALLERGIES
/
/
/
L_
/
Are there abnormalities of the following systems? Describe fully. Use additional sheet if needed.
Yes
No Describe
Ears, Nose, Throat
☐ ____________________________________________________
☐
Respiratory
☐ ____________________________________________________
☐
Cardiovascular
☐ ____________________________________________________
☐
Gastrointestial
Hernia
Genitourinary
☐
☐
☐
☐
☐
☐
☐
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
☐
______
Joint Abnormalities
☐
☐ ____________________________________________________
☐
☐ ____________________________________________________
Metabolic / Endocrine ______
☐
☐ ____________________________________________________
Neurologic
______
☐
☐ ____________________________________________________
Dermatologic
☐
☐ ____________________________________________________
Psychiatric
______
______
Is patient now under treatment for any medical condition?
Yes
No
If yes, your recommendations:______
______
Is patient now under treatment for any mental health condition?
Yes
No
If yes, your recommendations:______
____
Muscle tone / strength
Is this patient currently taking prescription medication? List below if yes.
Recommendations for physical activity:
Explain:
Unlimited
Yes
No
Limited
IMMUNIZATION FORM ****REQUIRED FOR REGISTRATION
Complete below or attach copy of immunization record
REQUIRED IMMUNIZATIONS
Rhode Island requires documentation of immunity in
order to register for college. Per RIH DOH,
nd
Persons born before 1957 are exempt from a 2 MMR.
RECOMMENDED IMMUNIZATIONS
Meningitis vaccine
Type:
Hep A #1
/
Date
#2
/
/
/
/
/
Tdap
/
/
(within last 10 years)
Dtap
/
/
(within last 10 years)
MMR #1 given at >1 year of age
/
/
MMR #2 given >28 days after dose #1
/
/
OR Proof of Measles, Mumps, Rubella immunity by titer*
* attach copy of laboratory titer results.
Hep B #1
/
/
#2
/
/
#3
/
/
or immunity*
* attach copy of laboratory titer results.
Varicella #1
/
/
#2
/
/
OR illness
/
_/
Physician signature:
Date of exam:
Address:
Phone:
/
/
Fax:
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RETURN FORMS TO: RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
Tuberculosis (TB) Risk Factor Screening (Part I)
/
Last name
First
Middle initial
/
Date of birth
Dear Physician:
Please review your patient’s risk factors using the following 5 factors.
Tuberculin testing is only indicated for individuals with any of the following risk factors for TB:
1.
2.
3.
4.
5.
Emigration from a country with a high incidence of TB (most countries of Asia, Africa, Eastern Europe, Central and South
America) - countries not listed in below table.
Travel to high-incidence country (not listed in below table) where housing was with family members or local residents - not
hotels, resorts, etc.
Household contact with parents or others who emigrated from a country with a high incidence of TB (not listed in below
table) and tuberculin status unknown.
Exposure to individuals in the past 5 years who are HIV-infected, homeless, institutionalized, users of illicit drugs,
incarcerated (test all groups every 2-3 years).
Immunocompromised (HIV infection - test yearly), diabetes mellitus, chronic renal failure, malnutrition, reticuloendothelial
diseases, other immunodeficiencies or receiving immunosuppressive therapy.
Australia
Austria
Belgium
Canada
Chile
Cyprus
Czech Republic
Denmark
Finland
France
Germany
Greece
Iceland
Ireland
Countries/Areas with low rates of Tuberculosis (TB)
Israel
Monaco
Italy
Netherlands
Jordan
New Zealand
Lebanon
Norway
Libya
Oman
Luxembourg
Slovakia
Malta
Slovenia
Sweden
Switzerland
U.S.A.
United Arab Emirates
U.K.
PHYSICIAN TO COMPLETE ITEM A OR B and sign below
A. o No risk factors were identified according to the above assessment and the Tuberculin Skin Test was not performed.
Healthcare Provider Signature:
(Required)
Telephone: (
)
Date:
Fax: (
/
/
)
Physician’s Stamp/Name:
B.
o
A risk factor has been identified according the above assessment and the Tuberculin Skin Test was performed.
Note: Test must be within 6 months of the first day of classes at RISD
PPD (Mantoux): Placed
/
/
mm/dd/yyyy
Read:
/
/
mm/dd/yyyy
Healthcare Provider Signature:
(Required)
Telephone: (
)
Fax: (
Result:
* (in mm)
(*If 5mm or more, complete
Part II – next page !")
Date: _/ _/
)
Physician’s Stamp/Name:
PHYSICIAN’S FORM-SIGNATURE REQUIRED
RETURN FORMS TO: RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
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Tuberculosis (TB) Risk Factor Screening (Part II)
/
Last name
First
Middle initial
/
Date of birth
Interpretation of Results
Risk Factor
Positive Result
Close contact with case of TB or is immunocompromised
5 mm or more
Born in country with a high rate of tuberculosis
10 mm or more
Traveled or lived for a month or more in a country with a high rate
of tuberculosis
No risk factors
10 mm or more
15 mm or more
If Tuberculin Skin Test is Positive, now or previously, the following are required:
1.
Date of Positive PPD:
Date:
/
2.
Chest X-ray: (Please attach copy of report)
o Normal
o Abnormal
/
(Describe)
3.
Clinical Evaluation:
o Normal
o Abnormal
(Describe)
4.
Medication Treatment Initiated:
o No (reason)
o Yes (Drug, Dose, Frequency, Dates Initiated/Completed)
Healthcare Provider Signature:
(Required)
Telephone: (
)
Date:
Fax: (
_/
_/
)
Physician’s Stamp/Name:
PHYSICIAN’S FORM-SIGNATURE REQUIRED
RETURN FORMS TO: RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
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Personal Medical History
Last name
First Middle initial
/
/
Date of birth
Street address
City
State
E-mail Address
Home Phone
Student Cell Phone
I. FAMILY HISTORY
Have any of your relations ever had any of the following?
Yes No Relationship
Cancer
☐ ☐
Tuberculosis
☐ ☐
Diabetes
☐ ☐
Kidney Disease ☐
☐
Heart Disease
☐ ☐
Intestinal disorder ☐ ☐
Zip Code
Yes No Relationship
Asthma/Hay fever
☐ ☐
Autoimmune disorder ☐ ☐
Epilepsy, Seizures
☐ ☐
Psychiatric illness
☐ ☐
Other:
II. PERSONAL HISTORY
Have you personally had any of the following?
Yes No
Eye Problems
☐ ☐
Ear, Nose, Throat Problems
☐ ☐
Recurrent headache/migraine
☐ ☐
Head injury/concussion
☐ ☐
Fainting spells/seizure
☐ ☐
ADD /learning disability
☐ ☐
Psychiatric/mental health disorder
☐ ☐
Substance abuse
☐ ☐
Eating Disorder
☐ ☐
Yes
☐
☐
☐
☐
☐
☐
☐
☐
Cardiac
Chronic cough
Tuberculosis/ positive PPD
Digestive disorder
Hepatitis/Liver disease
Cancer
Kidney/bladder disease
Joint disease/injury
No
☐
☐
☐
☐
☐
☐
☐
☐
If yes, describe:
List any surgical procedures:
List all allergies:
III. MEDICATIONS:
List all prescription and over-the counter medications taken on a regular basis in the past year, including vitamins, oral contraceptives, holistic meds.
Medication name
Dose
Condition
Current /Past
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
IV. TO BE COMPLETED AND SIGNED BY STUDENT (OR PARENT/GUARDIAN FOR STUDENTS UNDER AGE 18)
Meningococcal Meningitis Vaccine response: I have / my child has:
☐had the meningococcal meningitis immunization within the past 10 years. Type:
Date received:
/
☐read the information provided regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine.
☐ have decided that I (my child) will NOT obtain immunization against meningococcal meningitis disease.
Signature of student:
Signature of Parent or Guardian:
Date:
Date:
/
/
/
/
/
STUDENT/PARENT FORM-SIGNATURE REQUIRED
RETURN FORMS TO: RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
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Parental Permission / Emergency Contact Form
/
Student’s Last name
First
Middle initial
/_
Date of birth
I hereby grant permission to the of the Rhode Island School of Design or his / her authorized
representatives, to furnish such medical care as my son or daughter
(student’s full name) may require, including examinations, treatment,
immunizations, etc. This permission is conditioned on the understanding that in the event of a serious illness
or the need for hospitalization and /or major surgery, the college will use all reasonable efforts to contact me.
Failure of such efforts, however, should not prevent the College from providing such emergency treatment as
may be necessary for the best interest in the life of
(student’s full name).
I also acknowledge that the Rhode Island School of Design must abide by both Rhode Island State Law
and the individual policies of area hospitals with regard to consent to medical treatment of a minor. I
understand that in the event of a medical emergency I may be contacted directly by hospital staff as
necessary for the treatment or release of my son / daughter named above.
Signature of Parent or Guardian (required):
Date:
/
/
Date:
/
/
Emergency Contact Information:
Name
Name
Relationship
Relationship
Address
Address
OR
Home phone
Home phone
Cell phone
Cell phone
Work phone
Work phone
Is student allergic to any medication?
Is there any medical condition we should be aware of in case of an emergency?
Signature of Parent or Guardian (required):
RETURN FORMS TO: RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
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Student General Information Form
Name
Last
Summer Program :
First
☐ Summer Studies
Middle
☐ Pre-College
Are you currently enrolled as a full-time student @ RISD?
☐ Yes ☐ No
OFF CAMPUS ADDRESS (Complete only if applicable)
If you will be living at an off-campus address different from your permanent address, for the duration of the RISD Summer
Program, please fill in the following:
Summer Address
Apt. #
City
State
Country
Telephone
Zip Code
Cell Phone
PARENT OR GUARDIAN INFORMATION (Pre-College Students Only)
Name
Relationship to Student
Address
City
Home Telephone
State
Business Phone
Country
Cell Phone
Zip Code
E-mail
If you will be traveling during the Summer, it is important that we be able to reach you in the event of an emergency.
Please provide the offices of Health Services and Public Safety with you travel itinerary.
Telephone
Location
Dates of Stay
HEALTH INSURANCE POLICY INFORMATION
Compulsory for all students
☐ We have a medical insurance policy from a US domestic insurance company:
Company Name
Company Address (must be a US address)
Policy Number
Group Number
Subscriber’s Name
Date of Birth
Pre-Certification Telephone
☐ We have enrolled in the RISD offered health plan administered by University Health Plans
Policy Number
Subscriber’s Name
RETURN FORMS TO: RISD Health Services,Two College Street, Providence, RI 02903 / 401-454-6628 (fax) [email protected] (email)
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Health Insurance Information Sheet
RISD is committed to promoting good health and meeting the medical needs of its students. A health insurance plan is critical
in providing peace of mind, knowing that students can receive the services they need in the event of a sickness or injury.
The College requires all students to carry adequate medical insurance to help cover the extra expenses of medical treatment
that is not covered by our Health Services. All medical insurance policies must be from a U.S. domestic insurance
company. Non U.S. based Insurance companies or coverage provided in countries with socialized medicine, including
Canada, does NOT meet the insurance requirement.
To assist in providing your student with the coverage they will need during their summer studies at RISD, we have contracted
with the University Health Plans Insurance Program to offer The Pre-College Student Health Insurance Plan. The Plan includes
a local and national network of Preferred Providers, and is designed to be an affordable option. You can review the plan by
clicking on the University Health Plans website http://www.universityhealthplans.com/intro/RISD.html and selecting Rhode
Island School of Design. We urge you to enroll in this Plan for several reasons.
Although many families have some form of insurance, it's important to ensure that students are adequately covered while
attending school. All too often situations arise where a student requires medical or mental health care beyond what is available
at the RISD Health Center, only to discover that their insurance covers them only in the event of an emergency or in their
home geographic region. This frequently results in students having to take an otherwise unnecessary leave of absence from
their studies to return home in order to get the treatment they need. In other situations, the student’s insurance plan may
provide coverage in RI, but the list of providers they must choose from is extremely limited and often are not close to campus,
making access a significant problem. RISD Health Center staff members are rarely familiar with these providers and therefore
cannot assist the student with any recommendations. Further, coverage that is provided is often insufficient in meeting the
student’s need. The result is an added out of pocket expense for parents who must pay privately for adequate care.
To assist you in making an informed decision regarding your student’s health insurance needs, here are some general
questions to ask your current health plan to ensure that it provides adequate coverage:
• Does your current health plan provide coverage while in the area of the RISD campus? Many HMO plans provide
coverage for Emergency Treatment only, while out-of-area of the local HMO.
• Does your current health plan cover mental health services? Many employer-sponsored plans provide very limited
coverage for mental health services.
• Does your current health plan provide coverage anywhere in the world, including medical evacuation and
repatriation benefits?
• Does your current health plan include a nationwide network of Preferred Providers, guaranteeing acceptance of
your insurance plan, and reducing the student’s out-of-pocket expenses? Many employer-sponsored plans are
managed-care type plans, with a regionally based preferred provider network.
• Does your current health plan include Prescription Drug coverage, and a nationwide network of member
pharmacies? Many employer sponsored plans do not provide prescription drug coverage, or only very limited benefits
available at certain local pharmacies.
While many of students' health issues can be met by Health Services, there are times when referrals to community providers
are necessary. At such times, the Student Accident and Sickness Plan provides coverage worldwide and allows students to
seek care from any licensed provider, once the referral from RISD Health Services is made. Students also have access to a
nationwide Preferred Provider Network, as well as a national network of member pharmacies.
When students use a preferred provider, their out-of-pocket expenses can be limited as students’ coinsurance expenses are
based on negotiated Preferred Provider fees. The Plan provides coverage for expenses relating to injury or sickness including
diagnostic testing, lab and x-ray services, doctor visits, and prescription drugs.
It is your responsibility to carefully compare your current insurance plan with that offered by RISD through University Health
Plans to ensure that the coverage is truly comparable. Should you choose NOT to take the insurance plan sponsored by RISD
and offered through University Health Plans, you are attesting to the fact that you are familiar with both plans and will be
responsible for providing for your student’s medical and/or mental health needs should your own insurance prove insufficient.
We encourage you to read the information provided and take the time to make an informed decision regarding your health
coverage. Should you have questions regarding the The Pre-College Student Health Insurance Plan or to enroll, please
contact Marcia O'Neill at University Health Plans at 800-437-6448, xt.116 or go to
http://www.universityhealthplans.com/intro/RISD.html.
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RISD Health Services General Information
Health Services is a clinic staffed by nurse practitioners, nurses and office administrators who serve the needs of
RISD students. Health Services is an ambulatory care setting (i.e. sick visits and injuries). The health fee allows
all pre-college students to receive medical care from RISD’s Health Service regardless of their insurance. Insurance
is required for any medical services that a student may require outside of RISD’s Health Service.
Health Services
Homer Hall (lower Quad)
401-454-6625
Open Monday – Friday 7:30 am -5:00 pm
Except for emergencies, hours of operation are by appointment only.
Health Insurance
All students enrolled in the Pre-College Program must provide proof of insurance that meets the guidelines outlined
in the enclosed Health Insurance Information Sheet. Please carefully read the requirements before filling out the
Health Insurance Information Form.
Emergencies
If there is a medical or mental health emergency when Health Services and the Counseling Center are closed,
students should call Public Safety at 401-454-6666 or ext. 6666. A Public Safety Emergency Medical Technician
(EMT) will respond and the Administrator on-call will be notified. If necessary, Public Safety will arrange transportation
to an appropriate medical facility and/or arrangements will be made for the student to speak with the counselor on-call.
Specialists
When necessary, transportation to specialists in the community can be arranged through Health Services via cab.
Costs for transportation to medical facilities off-campus are the student’s responsibility. Students are financially
responsible for any medical services received off-campus.
Special Considerations
Parents or guardians who feel that their son or daughter may require special medical or mental health related
considerations must arrange for specialized care with a provider in the community. Parents or guardians are
encouraged to discuss these issues with Health Services before the student arrives on campus.
Medications
Students are expected to manage their supply and administration of all medications. Students can arrange to
have an account set up with a local pharmacy for delivery to Health Services. Students will then be notified when
to pick up their medications. For more information, please refer to the Pharmacies in Providence document
on our website at www.risd.edu/Students/Wellness/Health_Services/.
Counseling and Psychological Services
RISD’s Counseling and Psychological Services can provide psychological assessment and triage. If on-going care
is needed, counseling center staff will provide the student with a referral to a provider in the community. Costs for
transportation to clinicians off-campus are the student’s responsibility. Students are financially responsible for any
psychological services received off-campus.
We hope that your experience at RISD is satisfying and rewarding and we look forward to meeting you on check-in
day. In the meantime, if you have any questions regarding Health Services or the required medical forms, please
call us at 401-454-6625 or email us at [email protected].
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