La Salle University Initial Health and Immunization Form Page - 1

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1 La Salle University Initial Health and Immunization Form Page - 1 Attention Before your account can be created for the Health and Immunization Tracking System (hereafter called ITS ), you must have previously ordered a background check package on as your yearly subscription fee is included in that order. Once your payment has been received, please allow hour (business days) for American DataBank to create your account. Once created, we will send you your User ID and Password to the address that you provided in your background check order. Please be sure to use your LaSalle University address. When you have received your User ID and Password, please visit click on the Immunization Tracking button and then follow the directions on the ITS Home Page. Please note, you must provide all necessary forms and documents to American DataBank by scanning and uploading the documents into your Immunization Tracking System Profile, or by fax at Instructions for Entering Your Health and Immunization Records 1. Health & Physical Exam: Every 2 Years You must have a Health & Physical Exam every 2 years. Please enter the Health & Physical Exam Date on the Form and in the System. Form is available on website. You must scan and upload or fax a copy of your completed form to American DataBank. 2. Health Insurance: Every 2 Years You must have Health Insurance. Please enter the Health Insurance Issued Date and the Provider Name on the Form and in the System. You must fax or a copy of your proof of health insurance, if it is a card be sure to send the front and back. If you have any questions, please contact the Clinical Compliance La Salle University. 3. CPR by American Heart Association: Every 2 Years (CPR for Adult Infant and Child) You must have CPR Certification preferably by AHA for Health Care Providers. Please enter your CPR Certification Date on the Form and in the System and scan and upload a copy of the front and back of your card. CPR must be current throughout the program. 4. Urine Drug Screening: Yearly American DataBank will enter the test date in the System. American DataBank will mail you a Chain of Custody Form when you order your drug screen at this will be sent to the address you supplied with your order. You will need this form to take your drug test. 5. PA Child Abuse History Clearance: Yearly American DataBank will enter the test date in the System. Once you order your package at you must download and complete the Pennsylvania Child Abuse Clearance Form and mail it to the Dept. of Public Welfare with a $10.00 money order. You will get a peach-colored result certificate in the mail. Submit a copy of this certificate to American DataBank for processing. 6. FBI Fingerprinting: One Time American DataBank will enter the test date in the System. Once you place your order on American DataBank will register you for electronic fingerprinting and send you a Registration ID via within 1-3 Business Days. Once you complete your fingerprinting using the instructions on the site and in your , the DPW will process your prints within 2-3 weeks. You will get a blue-colored result certificate in the mail. Submit a copy of this certificate to American DataBank for processing. 7. Criminal Background Check Clearance: Yearly American DataBank will enter the test date in the System. Once you place your order at American DataBank will process your criminal background check within 1-3 Business Days (in most cases). When the results are complete, American DataBank will apply those results to your account. 8. PPD: Yearly <<See Page 6 of this Form>> **Note: Initial 2 Step PPD needs to be done within 1 to 3 weeks a part. If 2 Step PPD is Negative, then will need 1 PPD yearly** You must have a 2 Step PPD OR a Negative Quantiferon Gold Blood Test. If 1 st and 2 nd PPD OR Quantiferon Gold Blood Test are both Negative, please have your physician enter the 1st PPD and 2 nd PPD Given Date, Read Date, and Negative result on the Form. Be sure to also enter the results in the System. If a PPD OR a Quantiferon Gold Blood Test is Positive, you will need a Chest X-Ray with a Negative result to be compliant. The Chest X-Ray must be no older than 6 months prior to your start date with LaSalle. Enter your Chest X-Ray Date and Result Date on the Form and in the System. 9. Hepatitis B: One Time (Be sure to submit labwork for all titers) You must have all 3 shots of the Hepatitis B Vaccine and an Immune IGG Titer for Hepatitis B. Please enter the Date of Titer and result. If your Titer is Non-Immune you will need to restart the 3 shot series and complete a 2 nd Hepatitis B Titer. If any shots are missing from a repeat series, a note from your healthcare provider explaining the absence will be required. If applicable, enter the dates of the Repeat Shot Series and the Follow-up Titer on the Form and in the System.

2 La Salle University Initial Health and Immunization Form Page - 2 Instructions (Continued..) 10. Rubeola: One Time (Be sure to submit labwork for all titers) You must have a Rubeola IGG Titer with Immune result. If your Titer is NOT immune, then you must have 1 dose of Rubeola Vaccine or 1 MMR. Please enter the Titer Date and Result, or Rubeola Vaccination Date, or MMR date on the Form and the System. 11. Mumps: One Time (Be sure to submit labwork for all titers) You must have a Mumps IGG Titer with Immune result. If your Titer is NOT immune, then you must have 1 dose of Mumps Vaccine or 1 MMR. Please enter the Titer Date and Result, or Mumps Vaccination Date, or MMR date on the Form and in the System. 12. Rubella: One Time (Be sure to submit labwork for all titers) You must have a Rubella IGG Titer with Immune result. If your Titer is NOT immune, then you must have 1 dose of Rubella Vaccine or 1 MMR. Please enter the Titer Date and Result, or Rubella Vaccination Date, or MMR date on the Form and in the System. 13. Varicella (Chicken Pox): One Time (Be sure to submit labwork for all titers) You must have 2 doses of Varicella Vaccine or Varicella IGG Titer with Immune result. Please enter the Varicella Vaccine Date or Titer Date and Result on the Form and in the System. ***Date of Disease is NOT Acceptable*** 14. Tetanus/Diphtheria/Pertussis (Tdap/Adacel): One Time You must have a Tetanus/Diphtheria/Pertussis (Tdap/Adacel). Please enter the Tdap/Adacel Date on the Form and in the System. 15. Meningitis: One Time <<See Page 6 of this form>> If you are a Resident student, you must have received the Meningitis Vaccination. Please enter the Vaccination Date on the Form and in the System. If you are a Commuter student, you have the option of waiving the Vaccine but you must sign the Waiver. Please enter the Signed Waiver Date on the Form (on page 6 of this form) and in the System. 16. Flu Shot: Yearly You must receive a Seasonal Flu Vaccine yearly. Please enter the Date of Vaccination on the Form and in the System.

3 La Salle University Initial Health and Immunization Form Page - 3 Select Your Program of Study: Health Records Requirements: Initial Form Health & Physical Examination Main Campus Commuter Day Program Main Campus Resident Day Program Health & Physical Exam Date: (M) (D) (Y) Main Campus Achieve Program Bucks Campus Achieve Program Note: Official Documentation REQUIRED for ALL ITEMS Required Every Two Years : Health & Physical Form (See Pages 8-10) must be completed by a healthcare provider and attached. Is it attached? Yes No Are you receiving medical care for any health condition (this includes physical, psychological, mental, emotional conditions, prescribed medication, or conditions effecting sight, etc.)? Yes No If Yes, please specify: Health Insurance 2 -All Students must have current health insurance coverage. Required Every Two Years : Copy of Front and Back of Health Insurance Card Health Insurance Coverage (Current as of): (M) (D) (Y) Insurance Provider: American Heart Association Basic Life Support for the Healthcare Providers with AED Certification Required Every Two Years 3 -All Students must have CPR Certification through the AHA, which must be the AHA BLS for the Healthcare Provider CPR Certification (w/ AED Training) : Copy of Front and Back of CPR Card AHA BLS for the Health Care Providers w/ AED Certification (Certified on): (M) (D) (Y) Urine Drug Screening 4 American DataBank conducts the drug-screening for LaSalle. When the results are available, ADB Staff will enter that information into your ITS profile Pennsylvania Child Abuse Registry 5 You must submit the PA Child Abuse Registry Form to the Dept. of Public Welfare, and then send a copy of the resulting peach-colored certificate to ADB for processing. FBI Fingerprinting 6 American DataBank conducts the FBI Fingerprinting for LaSalle. When you receive results in the mail, send a copy of the resulting blue-colored certificate to ADB for processing. Criminal Background Check 7 American DataBank conducts the background checks for LaSalle. When results are complete, ADB Staff will enter that information into your ITS Profile. Required Every Year No Be sure to place order for drug screen, as instructed by LaSalle University, using the website: Required Every Year Copy of PA Child Abuse History Clearance Copy of PA Electronic FBI Fingerprint Results Required Every Year No Be sure to place order for background check, as instructed by LaSalle University, using:

4 La Salle University Initial Health and Immunization Form Page - 4 Health Record Requirements: Continued from Page 3 PPD (Tuberculosis Testing, Chest X-Ray, TB Screening Form): Pg 1 st Time: Students must have a 2-Step PPD, which is : 6 two tests 1-3 weeks apart OR a Negative If PPD Negative Quantiferon Gold Blood Test. Proof of PPD or Thereafter: Students must have 1 PPD OR Negative Quantiferon TB Gold Test, Quantiferon Gold Blood Test every year. either using the form on If Positive: Students with history of PPD Positive, pg. 6 below; or any official must document the event (One Time). AND have a documents showing date Chest X-Ray and TB Screening Form. and result of the testing. Thereafter: Students provide a TB Screening form annually and a Chest X-Ray every 10 years. PPD Negative Quantiferon Gold Blood Test PPD Positive Hepatitis B 9 Official Documentation REQUIRED for ALL ITEMS Required Every Year If PPD Positive Proof of the PPD or Quantiferon TB Gold Test Positive event, using the pg. 6, or other official documentation showing date and result. Copy of completed TB Screening Form; find it on the website. Copy of Chest X-Ray labwork printout. The Chest X- ray must be no older than 6 months prior to your start date at LaSalle. PPD 1 st Given Date: (M) (D) (Y) Read Date: (M) (D) (Y) Positive or Negative PPD 2 nd Given Date: (M) (D) (Y) Read Date: (M) (D) (Y) Positive or Negative Quantiferon Gold Blood Test Date: (M) (D) (Y) Positive or Negative PPD Positive Date: (M) (D) (Y) <One Time> Chest X-Ray Date: (M) (D) (Y) Result Date: (M) (D) (Y) Positive or Negative Chest X-Ray and TB Screening are both ANNUAL TB Screen Form Requirements Titers (Required) Shots (Required) Copy of Labwork Official documentation showing the dates of Printout showing date vaccinations (shot records, vaccination cards, note on and result of titer MD stationary, etc.) -All Students must have a 3-Shot Hepatitis B series AND get an Antibody (HBsAB) Titer. HepB 1 st Shot Date: (M) (D) (Y) HepB 2 nd Shot Date: (M) (D) (Y) HepB 3 rd Shot Date: (M) (D) (Y) Hepatitis B IGG Antibody Titer Date: (M) (D) (Y) / Immune: Yes or No Quantitative Titer Result: If Titer is Non-Immune Must Restart Series HepB 4 th Shot Date: (M) (D) (Y) HepB 6 th Shot Date: (M) (D) (Y) HepB IGG Re-Titer Date: (M) (D) (Y) Immune: Yes or No Quantitative Titer Result: MMR (Measles, Mumps and Rubella) 10 -All Students must have Antibody Titers drawn for Measles (Rubeola), Mumps and Rubella -If any titer is non-immune, you must have one booster for that disease *or* one MMR vaccine Measles Mumps Rubella HepB 5 th Shot Date: (M) (D) (Y) Titers (Required) Shots (If Given) Copy of Labwork Official documentation showing the dates of Printout showing date vaccinations (shot records, vaccination cards, note on and result of titer MD stationary, etc.) Rubeola IGG Antibody Titer Date: (M) (D) (Y) / Immune: Yes or No Quantitative Titer Result: If Non-Immune Rubeola/MMR Booster: (M) (D) (Y) Mumps IGG Antibody Titer Date: (M) (D) (Y) / Immune: Yes or No Quantitative Titer Result: If Non-Immune Mumps/MMR Booster: (M) (D) (Y) Rubella IGG Antibody Titer Date: (M) (D) (Y) / Immune: Yes or No Quantitative Titer Result: If Non-Immune Rubella/MMR Booster: (M) (D) (Y)

5 La Salle University Initial Health and Immunization Form Page - 5 Health Record Requirements: Continued from Page 4 Varicella 13 -Must have two vaccinations for Varicella OR an Immune Antibody Titer. -If the Titer is Non-Immune, you must show proof of 2 vaccinations, from some point (before or after the titer) Official Documentation REQUIRED for ALL ITEMS Titers (If Given) Shots (If Given) Copy of Labwork Official documentation showing the dates of Printout showing date vaccinations (shot records, vaccination cards, note on and result of titer MD stationary, etc.) A Varicella Shot #1 Date: (M) (D) (Y) Varicella Shot #2 Date: (M) (D) (Y) B Varicella Antibody Titer Date: (M) (D) (Y) / Immune: Yes or No Quantitative Titer Result: Tetanus Diphtheria and acellular Pertussis (TDaP/Adacel) 14 -Must have a TDaP one time, as an adult dose. -DTP adolescent and child series, as well as any other type of Tetanus vaccination, is not acceptable in lieu of the TDaP TDaP Vaccination Date: (M) (D) (Y) Meningitis Vaccination/Waiver Pg -All resident students are required to have 7 a Meningitis Vaccination, one time. -All other students are strongly recommended to have a Meningitis Vaccination, but may use the Declination on the Form if they choose to. Resident Student? Non-Resident ONLY Seasonal Flu Vaccination 16 -All students MUST have a seasonal flu vaccination, each flu season. Shot (Required) Official documentation showing the dates of vaccinations (shot records, vaccination cards, note on MD stationary, etc.) If you are a Resident Student Shot (Required): The Meningitis Form on pg. 7, signed by a healthcare provider; or official documentation showing the dates of vaccinations (shot records, vaccination cards, note on MD stationary, etc.) Meningitis Vaccination Date: (M) (D) (Y) Meningitis Waiver Form (Signed Date): (M) (D) (Y) Influenza Vaccination Date: (M) (D) (Y) If you are NOT a Resident Student Shot: The Meningitis Form on pg. 6, either signed by a healthcare provider, or official documentation Waiver: Complete the Meningitis Form on page 7 of this form. Required Every Year Flu Shot (Required) Official documentation showing the dates of vaccinations (shot records, vaccination cards, note on MD stationary, etc.) Flu Shot Waiver (Signed Date): (M) (D) (Y)

6 La Salle University Initial Health and Immunization Form Page - 6 Preliminary 2-Step PPD Screening One Time: Annual PPDs Thereafter For This Form to be Valid, ALL SECTIONS Must be Completed. If you have a Positive PPD History, Please Complete the Annual TB Questionnaire Form PPD#1 Date of Placement Site (Pick One) Right Arm Left Arm Lot# Expiration Date Placed by Signature Required To be Read Hours After Placement Date of Reading MM of Induration mm Read by Office Telephone Signature Required PPD#2 To be Given 1 Week to 3 Weeks After PPD #1 2-Step PPD is Only Required 1 st Time at LaSalle, Annual PPDs Thereafter Date of Placement Site (Pick One) Right Arm Left Arm Lot# Expiration Date Placed by Date of Reading MM of Induration Read by Office Telephone Signature Required Signature Required To be Read Hours After Placement mm

7 La Salle University Initial Health and Immunization Form Page - 7 A Meningitis Vaccine is required for ALL student residents (living on campus) at LaSalle University. See the University Student Health Policy for further information. Commuter students may sign a waiver to decline this vaccine. Meningitis is an inflammation of the membranes that cover the brain and spinal cord. People sometimes refer to it as Spinal Meningitis. Meningitis is usually caused by a viral or bacterial infection. Symptoms include: high fever, headache and stiff neck, nausea, vomiting, a discomfort looking into bright lights, confusion and sleepiness. The symptoms can develop over several hours, or they may take 1 to 2 days. If symptoms occur, the patient should see a doctor immediately. More information can be found on the CDC s website: ( ) Meningitis Waiver Decline I have read the information about the Meningococcal Meningitis Vaccine; I decline the vaccine at this time. I understand that in declining this vaccine, I continue to be at risk for this serious disease. Student Signature Signed Date OR Meningitis Vaccination Date Administered (MM/DD/YYYY) Physician/Healthcare Provider Name (Print) Physician/Healthcare Provider Signature Signed Date

8 La Salle University Initial Health and Immunization Form Page - 8 Health History and Physical Examination Form Pg 1 of 3 Day Program Main Campus Student Resident Select ALL that Apply: Evening Program Bucks Campus Commuter Last Name First Name Maiden Name or Birth Name (If Applicable) Date of Birth (MM-DD-YYYY) Country of Birth (If Not the United States, Please NOTE if US Citizen or Not) Permanent Address City State Zip Home Telephone Cellular Telephone Campus Address Campus Telephone LaSalle Address Emergency Contact Name Relationship Address City State Home# Work# Cellular# For This Form to be Valid, ALL Sections Must be Completed

9 La Salle University Initial Health and Immunization Form Page - 9 Health History and Physical Examination Form Pg 2 of 3 Dear Healthcare Provider: Students enrolled in health discipline majors may have encounters with individuals whose own health is compromised and those who may put the health of a student at risk. Thank you for your attention to the requirements when completing this form. Provider Information (Please Print or Stamp) Physician s Name Telephone Address City State Zip PLEASE PROVIDE COMPLETE INFORMATION RELATED TO THE FOLLOWING QUESTIONS: 1 Is the Student receiving medical care for any health conditions (this includes physical, psychological, mental or emotional conditions)? No Yes If Yes, Please Specify: 2 Does the Student have any drug allergies? No Yes If yes, please specify (including environmental/food allergies): 3 Latex Allergies? No Yes 4 Does the Student wear a Medical Alert Bracelet? No Yes If yes, please specify for what conditions the alert includes: For This Form to be Valid, ALL Sections Must be Completed

10 La Salle University Initial Health and Immunization Form Page - 10 Health History and Physical Examination Form Pg 3 of 3 Certification by Healthcare Provider I certify that I have reviewed the health history and completed the physical examination of Name of Student Date of Exam Check One: It is my medical opinion that this person Has no current physiological, psychological, emotional/mental, or cognitive conditions that would disqualify him/her from participating in a classroom and or clinical activities Has limitations that would affect his/her ability to participate in classroom and/or clinical activities. These limitations include: Signature of Healthcare Provider Date Student: Read and Sign I have read the above findings and certify that it s complete and accurate and that I have fully disclosed any conditions that may interfere with my ability to perform safely and responsibly in the classroom and clinical environment while a student at LaSalle University SONHS. I understand it is my responsibility to keep all information, testing and immunizations up to date. Failure to do so will prevent my participation in clinical activities. I agree to inform the clinical faculty of any health problems that may put my health or the health of others at risk while in the clinical area. Student s Signature Date Print Name For This Form to be Valid, ALL Sections Must be Completed

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