DEADLINE DATES: Summer 2013 Enrollment: Apr. 29, 2013 Fall 2013 Enrollment: Jul. 16, 2013 Spring 2014 Enrollment: Dec. 17, 2013

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1 DEADLINE DATES: Summer 2013 Enrollment: Apr. 29, 2013 Fall 2013 Enrollment: Jul. 16, 2013 Spring 2014 Enrollment: Dec. 17, 2013

2 Dear Student, Welcome to Columbia University Medical Center (CUMC). Here at the Student Health Service (SHS), we look forward to working with you to achieve optimal health and academic success. In order to accomplish those goals, we need your assistance in completing your preregistration health requirements. This brochure lists the required health information that you must provide to us in order to be able to register for classes. The information differs depending on your program, so please check carefully. Your clinician must complete the attached forms. If you have any questions, do not hesitate to contact us.* We look forward to welcoming you on campus, and to working with you during your time here. Sincerely, Melanie Bernitz MD, MPH Executive Director, CUMC Student Health Service Preregistration Health Requirements Non-Clinical Programs: Public Health, Human Nutrition, Graduate School of Arts and Sciences Clinical Programs: Dental, Medical, Nursing, Occupational Therapy, Physical Therapy, Post-Doctoral Fellows Important Notes: 1. You will be blocked from registering for classes until all preregistration health requirements are complete. Documentation must be received by your entering semester deadline (see below for s). Check your SSOL account 2 weeks AFTER deadline to verify health hold status. 2. Completed physical exam (if applicable) and immunization history forms must be submitted. 3. Copies of laboratory reports MUST be provided for all titers, antigens and Chest X-ray (if applicable). Numerical titers preferred. 4. Preregistration forms must be submitted regardless of choice of insurance plan. How to Submit (Do not send duplicate submissions): Preferred: Scan and ** completed forms to: If you are unable to or do not wish to send completed forms via , you may fax or mail: Fax: U.S. Postal Service Address: CUMC Student Health Service Mailbox 77, 630 West 168th Street, New York, NY FedEx Address (accepted 8AM - 5PM): CUMC Student Health Service Lobby Floor, 60 Haven Avenue, New York, NY Deadlines: Summer 2013 Enrollment: Requirements must be received by April 29, 2013 Fall 2013 Enrollment: Requirements must be received by July 16, 2013 Spring 2014 Enrollment: Requirements must be received by December 17, 2013 Fees will be charged to students completing any preregistration health requirements at Student Health Service ($25 on or prior to semester deadline and $75 after semester deadline). Additional fees are charged for each service rendered. See list at: Appointments can be scheduled by calling , prompt 1. *For questions concerning preregistration health requirements, call or For other inquiries about our comprehensive health care services and insurance, please visit our website at: **Documents are sent to a secure address. Ensure the address is entered correctly, so your health information does not go to the wrong address. You will receive a confirmation receipt. 1

3 NYS Requirements for All Students (including part-time students not enrolled in Student Health): q Measles/Mumps/Rubella: Non-Clinical Programs: Two doses of MMR vaccine (after 1 year of age) OR two doses of measles vaccine, one dose of mumps vaccine, and one dose of rubella vaccine OR positive titers (IgG) showing immunity. Clinical Programs: Two doses of MMR vaccine (after 1 year of age) AND positive titers (IgG) showing immunity to measles, mumps and rubella. An additional MMR vaccine is required if any titer is negative, inconclusive or equivocal. q Meningococcal Meningitis Response Form: Complete online after you receive your Columbia Uni at: Receipt of the vaccine is optional. Information on the vaccine is available at: CUMC Requirements for All Full Time Students, and Part Time Students Enrolling in Student Health Service: q Physical Exam: Must be completed by an MD, NP, or PA who is not a relative. The physical exam form can be found on page 4 of this brochure. q Health History: Enter online after you receive your Columbia UNI at: q Hepatitis B: Non-Clinical Programs: Three hepatitis B vaccines OR positive titer (IgG) showing immunity. Clinical Programs: Three hepatitis B vaccines AND a positive post-immunization titer (IgG) at least 30 days after last dose. If the hepatitis B titer is equivocal, inconclusive or negative, hepatitis B surface antigen is required within 6 months of program start. If negative, a 4th hepatitis B vaccine should be given. q Tetanus: Non-Clinical Programs: Td (Tetanus/diphtheria) within 10 years. One time adult dose of Tdap (Tetanus/ diphtheria/acellular pertussis) recommended but not required. Clinical Programs: One time adult dose of Tdap (Tetanus/ diphtheria/acellular pertussis) required, with Td (Tetanus/diphtheria) boosters every 10 years thereafter. q Polio: Date of most recent IPV (killed) or OPV (live) polio vaccines. q Tuberculosis Screening (within 6 months of deadline ): TB skin test (PPD) (unless previously positive). Receipt of BCG is not a contraindication to PPD. PPD preferred but Quantiferon Gold/TB Spot accepted. A baseline Chest X-ray (completed after positive test) is required ONLY for those with previously positive PPD, prior treatment for positive PPD, or a current PPD>10mm induration (>5mm in those who are HIV+ or with recent TB contact), or positive Quantiferon Gold/TB Spot. Additional Requirements for Students in Clinical Programs: q Varicella (Chicken Pox): Two doses of varicella vaccine at least 30 days apart OR positive varicella titer (IgG) if student has a history of chicken pox. If titer is negative, 2 doses of varicella vaccine at least 30 days apart are required. q Hepatitis C: Hepatitis C antibody within 6 months of program start. If hepatitis C antibody is positive, a quantitative hepatitis C RNA test is required. 2

4 Immunization Requirements All immunizations (including titers) must be submitted in English. Failure to do so will result in an incomplete application. Form must be completed by a clinician. LAB REPORTS FOR TITERS, ANTIGENS & X-RAYS ARE REQUIRED! Name: Telephone: DOB: UNI: Circle Program: SPH GSAS Nutrition Medical Dental OT PT ETP NP Post doc 1. Measles, Mumps, Rubella Immunity: Two MMR vaccines required. Positive titers are accepted if vaccine records are not available. MMR #1 MMR #2 *MMR #3 *MMR #3 required if any titer is negative Titers required for clinical students Measles Titer IgG Result Pos Neg (P&S, CDM, OT, PT, ETP, NP, Post doc) Mumps Titer IgG Result Pos Neg Rubella Titer IgG Result Pos Neg 2. Hepatitis B Immunity: Three vaccines required. Positive titers are accepted if vaccine records are not available. Hep B #1 Hep B #2 Hep B #3 *Hep B #4 *Hep B #4 required if Hep B sab & sag neg Titers required for clinical students Hep B Titer IgG Result Pos Neg Hep B Surface Antigen required only if titer is neg Hep B santigen Result Pos Neg 3. Tetanus/Diphtheria Vaccination: Required every 10 years. TD OR *Tdap *One time Tdap required for clinical students 4. Polio Vaccination: Most recent vaccine. IPV OR OPV 5. Tuberculosis Screening: Within 6 months of deadline. PPD Placed PPD Read Result Pos Neg Induration mm OR TB Spot/Quantiferon Gold Result Pos Neg (blood test) Complete the following section ONLY if PPD >10mm induration (>5mm if HIV + or recent contact) OR positive TB blood test. A baseline Chest X-Ray (completed after positive test) is required only for those with previously positive PPDs, prior treatment for positive PPD, or a current PPD >10mm induration (>5mm in HIV positive or TB recent contact), or positive TB blood test. Chest X-Ray Result Normal Abnormal History of BCG vaccine Yes No If Yes, Check if the student has any of the following symptoms: Cough Night Sweats Weight loss Has student been treated with INH or Rifampin?(Circle type) Yes No If Yes, from to Additional Requirements for Clinical Students: (P&S, CDM, OT, PT, ETP, NP, Post doc) 6. Varicella Immunity: Check titer only if student has history of chicken pox. Varicella Titer IgG Result Pos Neg OR *Varicella #1 Varicella #2 *Two varicella vaccines are required if titer is neg 7. Hepatitis C Titer: Within 6 months. Hep C Titer IgG Result Pos Neg *HCV Quantitative RNA Result Pos Neg * Required if Hep C titer is positive Please attach all other available immunization records especially if you have received Hepatitis A, Meningococcal, Typhoid, etc. Clinician Name/Title State License/Stamp please print Signature Date 3

5 Student Physical Form Must be completed by an MD, NP, or PA who is not a relative. Name: CUMC School: q Part-time q Full-time Last First M (Med, CDM, SON, SPH, GSAS, NUT, OT, PT, Post-Doctoral Fellow) Date of Birth: / / q Male q Female q Transgender Columbia Uni mo. day yr. Contact phone ( ) History Any significant finding in the student s past health history? q Yes q No If yes, please specify: Tobacco use: Alcohol use (drinks/wk): Other drug use: Any allergies to medications? q Yes q No Specify Any latex or other non-medication allergies? q Yes q No Specify (medication & reaction) Please list current medications and doses, including contraceptives, non-prescription medications, vitamins, and supplements: Physical Exam ( of exam must be within 12 months of school deadline ) Visual Acuity (with correction, if any): OD OS Correction? q Yes q No Height (inches) Weight (pounds) BP Pulse Normal Abnormal Not Done If Abnormal, please explain General appearance q q q Head q q q Eyes q q q Ears, Nose, Throat q q q Neck q q q Lymph Nodes q q q Breasts q q q Heart q q q Lungs q q q Abdomen q q q Pelvic Exam q q q GU Exam q q q Rectal Exam q q q Extremities q q q Neurological Exam q q q I certify that he/she is in good health and free of contagious disease q Yes q No Does this student require ongoing medical care? q Yes q No Specify: Date of Exam / / Clinician Signature License # () tear along perforation Clinician Stamp Tel. ( ) 4

6 Important Web Addresses SHS Website: WebPortal: 1 Student Health Service 2 Hammer Health Science Ctr. 3 William Black Research Building 4 Alumni Auditorium of Physicians and 5 College Surgeons 6 College of Dental Medicine 7 School of Nursing 8 Mailman School of Public Health

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