North Carolina A&T State University Sebastian Health Center 1601 E. Market Street Greensboro, NC Office Fax

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1 North Carolina A&T State University Sebastian Health Center 1601 E. Market Street Greensboro, NC Office Fax GUIDELINES FOR COMPLETING THE REQUIRED MEDICAL HISTORY PACKET The Sebastian Health Center welcomes you to the University. A variety of medical and health services are provided for all registered students between the hours of 8:00 a.m. and 9:00 p.m. (Monday - Friday). This Report of Medical History is designed to collect information about your health history and to verify that your immunizations are in compliance with the N.C. Immunization law. North Carolina state law requires all undergraduate and graduate students taking 4 hours or more on campus to provide documented proof of the required immunizations before registering for classes. These forms [ A Report of Medical History, B Family & Personal Health History, C Immunization Record, D Physical Examination (Required for Special Groups), E Meningococcal Vaccine Acknowledgement, and F HIPAA Acknowledgment] must be on file with the Student Health Center prior to May 15 th for fall registration and December 1 st for spring registration. If you are admitted to the university after the above dates, please return your information before your scheduled new student orientation date. Completion of these forms is required to finalize your acceptance to North Carolina A&T State University. Enrollment suspension procedures from classes will take place 30 days after registration, until immunizations and requirements are documented. Do not complete this form in pencil. Use a black ink ballpoint pen or type. Attach copies of immunization records obtained from high school, military service and medical facilities, that may be used towards meeting the immunization requirements. NOTE: RECORDS MUST HAVE AN OFFICIAL SEAL / STAMP OR PHYSICIAN S SIGNATURE TO BE VALID. If you have not received two (2) Measles, Mumps Rubella, you will be required to receive two (2) dosages (an initial dose and the second dose within (6) weeks). Give special attention to showing proof of the Tetanus series: 3 doses of DTP / DTaP / Td and a Tetanus Booster (Tdap) within the last 10 years. A Physical Examination is recommended. The physical form should be completed by a licensed physician for all incoming freshmen and transfer students to the University prior to the first day of class. Special Groups are required to complete the Physical Examination and Sickle Cell Testing. ( Band, ROTC, Student Athletes, Intramural Sports). International students are required to provide proof of a negative PPD/Tuberculin skin test within 12 months proceeding the first day of classes. If your PPD/TB is positive, a chest x-ray may be performed within the United States. Students requesting medical exemption regarding NC Immunization Laws, are required to have a MEDICAL EXEMPTION STATEMENT completed and signed by your physician and submitted to the Student Health Center prior to registration. Students requesting religious exemption regarding NC Immunization Laws, are required to have a RELIGIOUS EXEMPTION STATEMENT completed and submitted to the Student Health Center prior to registration. Read this form carefully and submit all required information as instructed to the health center via fax or mail, or in person. An Equal Opportunity / Affirmative Action Employer A Constituent Institution of THE UNIVERSITY OF NORTH CAROLINA SYSTEM Rev 05/10; 10/10;2/11

2 North Carolina Agricultural and Technical State University Sebastian Health Center New Student Medical History Packet Checklist Dear Prospective Aggie: Welcome to the University! In an effort to assist with medical compliance, we are sending this correspondence to all new students. The enclosed Medical History Packet contains information that is vital in completing the NC Immunization Requirements. North Carolina state law requires all undergraduate and graduate students taking 4 hours or more on campus to provide documented proof of the required immunizations before registering for classes. Please return only the below documents to Sebastian Health Center. The other documents are for your review and to keep in your files. Please return the enclosed documents via fax / mail by May 15 th for fall registration and December 1 st for spring registration. If you are admitted to the university after the above dates, please return your information before your scheduled new student orientation date. Report of Medical History /Family & Personal Health History (2 pages) (Form A / B) Immunization record / a copy of your personal immunization record / card (Form C) A Physical examination is recommended (Must be completed by a Physician, Nurse Practitioner or Physician Assistant) (Form D) Meningococcal Vaccine Acknowledgement Form (Form E) HIPAA Acknowledgment Form (Form F) We look forward to servicing your health care needs. Please do not hesitate to contact the Sebastian Health Center (SHC) at (336) for additional information regarding the Medical History Packet. Aggie Pride! A Land-Grant University and A Constituent Institution of the University of North Carolina 1601 East Market St Greensboro, NC (336) Fax (336) Rev 08/10; 11/10; 2/11

3 North Carolina A&T State University Sebastian Health Center Fax Revised 05/08; 3/11 3

4 Form A 4

5 Form B 5

6 IMMUNIZATION RECORD Form C Last Name First Name Middle Name Date of Birth(mo./day/year) Banner ID# (Please print in black ink) Student to confirm identifying information above is complete before submission. All other information to be completed and signed by physician or clinic. A complete immunization record from a physician or clinic may be attached to this form.) SECTION A REQUIRED IMMUNIZATIONS mo./day/year mo./day/year mo./day/year mo.day/day/year DTP, DTaP,TD, or Tdap (#1) (#2) (#3) (#4) Tdap Booster (If due update after 7/2008) Td Booster Polio MMR (2 doses after 1st birthday) Measles / Rubella (MR) (after first birthday) Measles (2 doses after 1st birthday) Mumps Rubella * Hepatitis B (required if born 7/1/94 or after) (#1) (#2) (#3) International Student Requirements: Tuberculin (PPD) Test Date Given (within 12 months) Date Read mm in duration Chest X-ray, if positive PPD Date (Report result in mm induration) Result Treatment if applicable Date **Disease Date ****Titer Date& Result **(Disease Date ****Titer Date& Result NOT Accepted) **(Disease Date ****Titer Date& Result NOT Accepted) SECTION B RECOMMENDED IMMUNIZATIONS The following immunizations are recommended for all students and may be required by certain colleges of departments (for example, health sciences). Please consult your college or department materials for specific requirements. Meningococcal Vaccine: No ( ) Yes ( ) Which vaccine? Menactra ( ) Menomune ( ) Date Given: Hepatitis B series only Hepatitis A/B combination series Varicella (chicken pox) series of two doses or immunity by positive blood titer mo./day/year mo./day/year mo./day/year Disease Date ****Titer Date& Result ****Titer Date& Result SECTION C OPTIONAL IMMUNIZATIONS SECTION D SICKLE CELL mo./day/year mo./day/year Date Of Test: / / Haemophilus influenza type b Pneumococcal Results: Hepatitis A series only Positive / Negative Typhoid Trait Influenza HPV (Gardasil) *** Laboratory proof of Sickle Cell testing must be attached Other to records*** Signature or Clinic Stamp REQUIRED: Signature of Physician/Physician Assistant/Nurse Practitioner Print Name of Physician/Physician Assistant/Nurse Practitioner Date Area Code/Phone Number Office Address City State Zip Code ** Must repeat Rubella (measles) vaccine if received even more than 4 days prior to 12 months of age. History of physician-diagnosed measles disease is acceptable, but must have signed statement from physician. *** Only laboratory proof of immunity to rubella or mumps is acceptable if the vaccine is not taken. History of rubella or mumps disease, even from a physician, is not acceptable. **** Lab Report must be submitted. Rev 08/08; 11/10; 1/11

7 Mail To: NORTH CAROLINA A&T STATE UNIVERSITY SEBASTIAN HEALTH CENTER Form D 1601 E. MARKET STREET GREENSBORO, NC ( Required For Special Group) A physical examination is recommended. This form must be completed in black ink and signed by a Physician or Physician Assistant. Banner Banner ID#ID # Hgb or Hct STS (may be required by some departments) Date Results 7

8 North Carolina Agricultural and Technical State University Sebastian Health Center Immunization Recommendations for Meningococcal Meningitis Disease Dear Parent or Guardian: On behalf of North Carolina Agricultural and Technical State University, I am writing to inform you about meningococcal disease, a rare, but potentially fatal, bacterial infection commonly referred to as meningitis, and a new immunization recommendation that may affect your college-bound students. The U.S. Centers for Disease Control and Prevention (CDC) and the American College Health Association (ACH) have approved new recommendations that urge all first-year students living in residence halls to be immunized against meningococcal disease. The CDC and ACHA recommendations further state college students under the age of 25 years who wish to reduce their risk for the disease may choose to be vaccinated. College students living in residence halls are more likely to contract meningococcal disease than the general college population, due to lifestyle factors, such as crowded living situations, bar patronage, active or passive smoking, irregular sleep patterns, and sharing personal items. Meningitis is contagious and is spread through air droplets and direct contact with infected persons. Meningococcal disease strikes 1,400 to 3,000 Americans each year and is responsible for approximately 150 to 300 deaths. Adolescents and young adults account for nearly 30 percent of all cases of meningitis in the United States. In addition, approximately 100 to 125 cases of meningococcal disease occur on college campuses each year, and five to 15 students will die as a result. Know how meningitis is spread Know the symptoms (often mistaken for the flu) Know when to seek medical help Know about the vaccine that helps prevent meningitis The Sebastian Health Center offers the Meningococcal Vaccine at a cost of $ Students may pay for the vaccine by check, cash, credit card, Aggie One Card, or they may bill the charge to their account. Vaccination can prevent most cases of the disease and the vaccine is a covered benefit, paid under the Student Health Insurance Policy. Don t let meningitis stop you from enjoying college life and obtaining your goal. Talk to your doctor about the meningococcal vaccination, and do it before you head off to college. For more information about meningitis and vaccination, visit the Sebastian Health Center (SHC). You also can visit the websites of the American College Health Association, and the Centers for Disease Control and Prevention. Sincerely, Linda R. Wilson Linda R. Wilson Executive Director Sebastian Health Center A Land-Grant University and A Constituent Institution of the University of North Carolina 1601 East Market St Greensboro, NC (336) Fax (336) Rev 7/08;08/10

9 Form E Dear On-Campus Housing Student: Effective November 1, 2003, North Carolina law recommends that every student enrolled at a University, and who resides in on-campus housing, be vaccinated against meningococcal disease. The parent or guardians of the student to sign the acknowledgement form if the student is a minor (under age 18). 18 YEARS OR OLDER I am 18 years of age or older. I have received and reviewed the information provided on the risk of meningococcal disease and the effectiveness and availability of meningococcal vaccine. I understand that North Carolina law recommends that an individual enrolled in an institution of higher education in North Carolina, who resides in on-campus student housing, shall receive vaccination against meningococcal disease. I voluntarily agree to release, discharge, indemnify and hold harmless the State of North Carolina, the University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from any non-compliance with the law. I acknowledge receiving the meningococcal vaccine information. Patient Name (please print) Signature of Patient Student Banner ID# Date INDIVIDUALS UNDER THE AGE OF 17 I have received and reviewed the information provided on the risk of meningococcal disease and the effectiveness and availability of meningococcal vaccine. I understand that meningococcal disease is rare but life threatening illness. I understand that North Carolina law recommends that an individual enrolled in an institution of higher education in North Carolina who resides in on-campus student housing shall receive vaccination against meningococcal disease. I voluntarily agree to release, discharge, indemnify and hold harmless the State of North Carolina, the University, its officers, employees and agents from any and all costs, liabilities, expenses, claims, demands, or causes of action on account of any loss or personal injury that might result from any non-compliance with the law. I acknowledge receiving the meningococcal vaccine information for my child, Name of Child (Child s Banner ID #) Signature of Parent/Guardian Date

10 North Carolina Agricultural and Technical State University Sebastian Health Center Privacy Policy (HIPAA) Statement Student Health Services and HIPAA You are more than likely familiar with a federal law pertaining to health records called HIPAA. In fact, you may have received something called a HIPAA Notice of Privacy Practices from your family doctor, your health insurance company, or your neighborhood pharmacy. HIPAA, the Health Insurance Portability and Accountability Act of 1996, is a Federal Regulation dealing with health records. The purpose of the Act is to ensure the privacy and security of Protected Health Information (PHI) with regards to a patient record. Student Health Services Notice of Privacy Practices We are required by federal law to maintain the privacy of health information about you called protected health information (PHI). We are also required to provide you notice of our obligation to protect your PHI and to explain our privacy practices. This notice describes how information about you may be used and disclosed to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law and how you can get access to this information. If you have any questions about this notice, contact North Carolina Agricultural and Technical State University Student Health Services (336) Our Pledge Regarding Medical Information At North Carolina Agricultural and Technical State University s Health Center, we are committed to keeping your protected health information (PHI) confidential. The Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. Disclosure may occur without your authorization for purposes of treatment, judicial or administrative orders, payment, and health care operations. However, Sebastian Health Center will comply with all HIPAA laws as it represents the highest standard available for protection of your confidential health information. We reserve the right to change our privacy practices and to make any new provisions effective for all protected health information we maintain. If we change our notice, we will post the revised notice in the facility and will have it available upon request. You can receive a copy of the current notice at any time. The effective date is listed just below the title. You will be asked to acknowledge in writing your receipt of this request. We will not use or disclose your health information without your signed authorization, except as described in this notice. All health records are destroyed eight (8) years after the student has left the University. A Land-Grant University and A Constituent Institution of the University of North Carolina 1601 East Market St Greensboro, NC (336) Fax (336) Rev 6/07; 7/08

11 Form F North Carolina Agricultural and Technical State University Sebastian Health Center Health Insurance Portability and Accountability Act (HIPAA) Patient s Acknowledgment Form Dear Prospective Aggie: Welcome to the University! In an effort to assist with medical compliance, we are sending this correspondence to all new students. We are required to obtain your specific written authorization to use or disclose your Protected Health Information for purposes unrelated to treatment, payment, or health care operations. We also may use and disclose your Protected Health Information to provide you with information regarding possible alternative treatment options and other health-related benefits and services that we believe might interest you. However, there are exceptions to this general rule under which we are permitted or required to make certain uses and disclosures of such information without your authorization. These situations include: Required by the Secretary of Health and Human Services Domestic Armed Forces Personnel Judicial and Administrative Proceedings Coroners, Medical Examiners, and Funeral Directors Required by Law Health Oversight Public Health I acknowledge that I was provided my personal copy of my Privacy Policy (HIPAA) statement to read and keep as my own. Patient Name (Please Print) Signature of Patient/Parent/Responsible Party Print Name of Parent/Responsible Party / / Date Patients Date of Birth / / Patients Banner ID 950 We look forward to servicing your health care needs. Please do not hesitate to contact the Sebastian Health Center (SHC) at (336) for additional information. Aggie Pride! A Land-Grant University and A Constituent Institution of the University of North Carolina 1601 East Market St Greensboro, NC (336) Fax (336) Rev 08/10

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