ST. JOHN S STUDENT-ATHLETE SPORTS MEDICINE CHECKLIST

Transcription

1 ST. JOHN S STUDENT-ATHLETE SPORTS MEDICINE CHECKLIST Prior to participating with St. John s Athletics, you will receive several medical forms. Each form is important and must be completed prior to participation in athletics and enrollment at this university. While some of the forms may seem repetitive, it is necessary to complete each as different offices on campus require similar forms. If these forms are not complete, you will not be cleared to participate in intercollegiate athletics at St. John s University. Therefore, we ask that you PLEASE MAKE CERTAIN YOU FILL OUT AND RETURN EVERYTHING asked by each of the following offices. Please use this checklist to help ensure you have completed all the necessary forms. 1. SPORTS MEDICINE DEPARTMENT Insurance Info & Demographic Form with photocopies of ALL insurance cards Student-Athlete Initial Health History Questionnaire ADHA/ADD NCAA Info for Drug Testing Medical Exceptions Acceptance of Risk/Liability Waiver & Consent of Medical Care & Treatment Sickle Cell Trait Info & Waiver Form HIPAA Form Authorization for Use & Disclosure of Protected Health Info Original STJ Physical Examination Form & Medical Examination Form completed by your physician within the past 6 months Important phone numbers: Sports Medicine: (718) Student Health Services: (718) **Please do not disregard any of the forms you receive. **Please mail your completed packet to: Ron Linfonte, ATC St. John s University Sports Medicine Taffner Arena 8000 Utopia Parkway Jamaica, NY 11439

2 ACCEPTANCE OF RISK/LIABILITY WAIVER & CONSENT OF MEDICAL CARE & TREATMENT Please read completely and carefully, and sign below: a) The undersigned hereby certifies that the answers to the Sports Medicine health history questionnaire and physical examination are correct, true, and honest. b) We understand that having passed the pre-participation medical/physical examination does not necessarily mean that the student-athlete is physically qualified to engage in athletics, but only that the examiner did not find a medical reason to disqualify them. c) We understand and accept the risks of injury, the possibilities of permanent disability, and death inherent to the relevant sport. By signing below the student-athlete pledges to do the best to reduce these risks by keeping in the best physical condition and following the advice of the team physician, attending physician, certified athletic trainer (ATC), and coaching staff concerning the prevention, treatment, and rehabilitation of athletic injuries. d) A concussion is a complex patho-physiological process affecting the brain, induced traumatic biomechanical forces and is characterized by a rapid onset of cognitive impairment. Although a concussion most commonly occurs after a direct blow to the head, it can occur after a blow elsewhere that is transmitted to the head. Athletes that are not fully recovered from an initial concussion are significantly vulnerable for recurrent, cumulative, and even catastrophic consequences of a second concussive injury. By signing below the student-athlete is acknowledging an understanding of the risk associated with concussion and pledges to report all head trauma to an ATC. e) We grant permission to the Sports Medicine Staff to hospitalize and/or secure treatment for me for any athletic injury. If the student-athlete is under the age of 18, the undersigned parent grants permission to the Sports Medicine Staff to hospitalize and secure treatment for my son/daughter for any athletic injury. f) I give permission for Certified Athletic Trainers (within the Athletic Department), the St. John s University Student Health Center Staff, and all consulting physicians, permission to exchange, written or orally, any information concerning any injuries or illness which effects my ability to participate in physical activities throughout the time in which I am an official student athlete at St. John s University. Any change in this status must be made in writing by the student athlete and rendered to all parties concerned. We, the undersigned, have read and understand the Medical Policy statement and agree to follow its policies and procedures. We also hereby release St. John s University, its agents and employees, from any liability caused by, or arising out of the athletic participation in the University s athletic program, unless solely caused by the negligence of the University, its agents, or employees. Athlete s signature Parent s signature* Date Date **Parent s signature required if student-athlete is under 18 years of age.

3 Sports Medicine NCAA Information for Drug Testing Medical Exceptions To All Incoming Freshmen / Transfer and Returning Student Athletes and Parents / Legal Guardians: As you are aware, the NCAA conducts random drug testing of student athletes. More information about the NCAA s year-round drug testing policy, including impermissible substances can be found at A student whose drug test results are positive for banned substances will generally be declared immediately ineligible for competition. The NCAA recognizes, however, that some banned substances are used for legitimate medical purposes, and will grant exceptions from a positive drug test for those student athletes who are able to provide medical records which demonstrate that they have a medical need and current prescription for a banned substance, including medications prescribed for male-pattern baldness, stimulants used to treat ADD/ADHD, peptide hormones (hgh), and anabolic steroids (testosterone). Student athletes are responsible for notifying the Sports Medicine Staff that they are taking prescription medications for which they may require a medical exception from a NCAA drug test. If a student athlete is taking a prescription medication, the student should submit documentation from the prescribing physician to support the prescription to the Athletic Training Room at the beginning of each academic year, and update this information as prescriptions change. All documentation related to a student athlete s medical status will be kept in a confidential file in the Department of Athletics and will not be disclosed to the NCAA or other third party, unless specifically requested by the NCAA in connection with a positive drug test. NOTE TO STUDENTS DIAGNOSED WITH ADD/ADHD: Beginning August 1, 2009, the NCAA has indicated that there will be a stricter application of the NCAA Medical Exception Policy as it applies to banned stimulant medications used to treat Attention Deficit Hyperactivity Disorder (ADHD). This stricter application will require documentation that demonstrates the student athlete has undergone a clinical assessment to diagnose ADHD, is being monitored regularly for use of the stimulant medication, and has a current prescription on file. Detailed information about the NCAA s specific requirements for a medical exception for ADHD prescription medication may be found at These documentation requirements are very stringent. To avoid prolonged periods of ineligibility in the event of a positive drug test, St. John s University strongly recommends that students with current prescriptions for medication for ADHD keep the required documentation on file with the Sports Medicine Staff so that it may be produced promptly to the NCAA in the event of a positive test. The specific documentation requirements for students taking prescription medication for ADHD are described in the attached guidelines from the NCAA. (See NCAA Banned Drugs and Medical Exception Policy Guidelines Regarding Medical Reporting for Student Athletes with Attention Deficit Disorder (ADHD) Taking Prescribed Stimulants.) The Sports Medicine staff is also available to answer any questions student athletes or their parents may have about the NCAA s drug testing program, its medical exception procedure, or the ADHD documentation requirements. As a condition of your participation in St. John s University Athletics, please sign below to acknowledge that you understand the NCAA rules and requirements related to drug testing. By signing below, I understand that it is my responsibility, for my own health and safety as well as for the purposes of NCAA drug testing, to keep my medical file current with the Sports Medicine Staff at all times. This includes, but is not limited to, ensuring that my file contains a complete list of any medication that I am currently prescribed for any medical condition(s). I understand that certain medications may be banned by the NCAA, and I give my permission to St. John s University to provide some or all of medical records to the NCAA to petition for a medical exception in the event that I test positive on a NCAA drug test. Student-Athlete Date of Birth Sport Student Athlete s Signature Print Name Date Parent or Legal Guardian s Signature if Student Athlete is under 18 Date

4 NCAA Banned Drugs and Medical Exceptions Policy Guidelines Regarding Medical Reporting for Student- Athletes with Attention Deficit Hyperactivity Disorder (ADHD) Taking Prescribed Stimulants The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in competition. Some legitimate medications contain NCAA banned substances, and student-athletes may need to use these medicines to support their academics and their general health. The NCAA has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The diagnosis of adult ADHD remains clinically based utilizing clinical interviews, symptom-rating scales, and subjective reporting from patients and others. The following guidelines will help institutions ensure adequate medical records are on file for student-athletes diagnosed with ADHD in order to request an exception in the event a student-athlete tests positive during NCAA Drug Testing. 1. General considerations. Student-athletes diagnosed with ADHD in childhood should provide records of the ADHD assessment and history of treatment. Student-athletes treated since childhood with ADHD stimulant medication but who do not have records of childhood ADHD assessment, or who are initiating treatment as an adult, must undergo a comprehensive evaluation to establish a diagnosis of ADHD. There are currently no formal guidelines or standards of care for the evaluation and management of adult ADHD. The diagnosis is based on a clinical evaluation. ADHD is a neurobiological disorder that should be assessed by an experienced clinician and managed by a physician to improve the functioning and quality of life of an individual. a. Student-athletes should have access to a comprehensive continuum of care including educational, behavioral, psychosocial and pharmacological services provided by licensed practitioners who have experience in the diagnosis and management of ADHD. Student athletes treated with ADHD stimulant medication should receive, at a minimum, annual clinical evaluations. b. Mental health professionals who evaluate and prescribe medical therapy for student-athletes with ADHD should have appropriate training and experience in the diagnosis and management of ADHD and should have access to consultation and referral resources, such as appropriate medical specialists. c. Primary care professionals providing mental health services (specifically the prescribing of stimulants) for student-athletes with ADHD should have experience in the diagnosis and management of ADHD and should have access to consultation and referral resources (e.g., qualified mental health professionals as well as other appropriate medical specialists). 2. Recommended ways to facilitate academic, athletics, occupational and psychosocial success in the college athlete with adult ADHD taking prescribed stimulants include: a. Access to practitioners experienced in the diagnosis and management of adult ADHD. b. A timely, comprehensive clinical evaluation and appropriate diagnosis using current medical standards. NCAA Medical Exceptions Policy c. Access to disability services. d. Appropriate medical reporting to athletics departments/sports medicine staff. e. Regular mental health/general medical follow-up. 3. Student-Athlete Document Responsibility. The student-athlete s documentation from the prescribing physician to the athletics departments/ sports medicine staff should contain a minimum of the following information to help ensure that ADHD has been diagnosed and is being managed appropriately (see Attachment for physician letter criteria): a. Description of the evaluation process which identifies the assessment tools and procedures. b. Statement of the Diagnosis, including when it was confirmed. c. History of ADHD treatment (previous/ongoing). d. Statement that a non-banned ADHD alternative has been considered if a stimulant is currently prescribed. e. Statement regarding follow-up and monitoring visits. 4. Institutional Document Responsibility. The institution should note ADHD treatment in the student-athlete s medical record on file in the athletics department. In order to request a medical exception for ADHD stimulant medication use, it is important for the institution to have on file documentation that an evaluation has been conducted, the student-athlete is undergoing medical care for the condition, and the student-athlete is being treated appropriately. The institution should keep the following on confidential file: a. Record of the student-athlete s evaluation. b. Statement of the Diagnosis, including when it was confirmed. c. History of ADHD treatment (previous/ongoing). d. Copy of the most recent prescription (as documented by the prescribing physician). 5. Requesting an NCAA Medical Exception: a. The student-athlete should report the banned medication to the institution upon matriculation or when treatment commences in order for the student-athlete to be eligible for a medical exception in the event of a positive drug test. b. A student-athlete s medical records or physician s letter should not be sent to the NCAA, unless requested by the NCAA. c. The use of the prescribed stimulant medication does not need to be reported at the time of NCAA drug testing. d. Documentation should be submitted by the institution in the event a student-athlete tests positive for the banned stimulant. Note: The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports may approve stimulant medication use for ADHD without a prior trial of a non-stimulant medication. Although the NCAA Medical Exception Policy requires that a non-banned medication be considered, the medical community has generally accepted that the non-stimulant medications may not be as effective in the treatment of ADHD for some in this age group.

5 Attention Deficit Hyperactivity Disorder (ADHD) Guideline Attachment Criteria for letter from prescribing Physician to provide documentation to the Athletics Department/Sports Medicine staff regarding assessment of student-athletes taking prescribed stimulants for Attention Deficit Hyperactivity Disorder (ADHD), in support of an NCAA Medical Exception request for the use of a banned substance. The following must be included in supporting documentation: Student-athlete name. Student-athlete date of birth. Date of clinical evaluation. Clinical evaluation components including: 1. Summary of comprehensive clinical evaluation (referencing DSM-IV criteria) -- attach supporting documentation. 2. ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report summary attach supporting documentation. 3. Blood pressure and pulse readings and comments. Note that alternative non-banned medications have been considered, and comments. 4. Diagnosis. 5. Medication(s) and dosage. 6. Follow-up orders. Additional ADHD evaluation components if available: Report ADHD symptoms by other significant individual(s). Psychological testing results. Physical exam date and results. Laboratory/testing results. Summary of previous ADHD diagnosis. Other comments. Documentation from prescribing physician must also include the following: Physician name (Printed) Office address and contact information. Specialty. Physician signature and date. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.

6 DRUG TESTING POLICY PHILOSOPHY: The abuse of alcohol and illicit use of drugs can be detrimental to the physical well being of its student-athletes. Substance abuse by student-athletes jeopardizes athletic performance, and is contrary to NCAA regulations and the expectations of St. John s University. Each student-athlete is required to review the banned substance list and sign the NCAA Drug Test Consent Form prior to the first practice or other date as designated by the NCAA. The NCAA Drug Testing Policy applies to all student-athletes. Testing of student-athletes may occur at any time during the year, whether they are in-season or not. Any individual who tests positive for an NCAA drug test will be declared ineligible for further participation. The drug testing program is under the direction of the St. John s University Physician whose role is to coordinate all steps of the drug testing procedure. Drug testing will be conducted throughout the year. In addition, a student-athlete may be subject to testing at any time when, in the judgment of the Director of Athletics, there is reasonable cause to suspect the student is engaged in the use of any of the drugs prohibited by this policy. Such individualized suspicion may be based on information from any source deemed reliable by the Director of Athletics. DRUG TESTING PROCEDURE: The Office of Athletics may request all student-athletes to volunteer a urine specimen to be analyzed upon request at any time during the academic year. The student-athlete is notified by a member of the athletic training staff when to report for testing. The collection procedures are as follows: The Office of Athletics may request all student-athletes to volunteer a urine specimen to be analyzed upon request at any time during the academic year. The student-athlete is notified by a member of the athletic training staff when at report for testing. The studentathlete will to present his/her photo ID for proper identification. The ATC will sign the donor identification form and note the date/time. The student-athlete is then asked to remove all outer wear (jackets, sweats, sweatshirts, etc.). This clothing along with all backpacks/bags will be left in the athletic training room. The ATC will then ask to view the contents of student-athletes pockets and have all unnecessary items removed. Studentathlete will be asked to select a collection specimen box, open it and unseal the collection cup. A same gender staff member will then escort the student-athlete to the test site lavatory where they will be directly observed voiding into a collection cup a minimum of 60mL of urine. The student-athlete will then take the cup, untouched by anyone else, to the collection site. Temperature of the specimen will then be noted (ph and specific gravity may be tested additionally). The specimen will then pour, by the ATC, into the collection vial chosen by the student-athlete. The ATC and student-athlete will complete the chain of custody (COC) forms and apply the bar code label seals on the specimen vial.specimens will then be shipped either same day or next day by air courier. ATHLETES WHO FAIL TO SHOW FOR A SCHEDULED DRUG TEST AFTER THEY HAVE BEEN NOTIFIED OR FAIL TO SHOW FOR MANDATORY DRUG COUNSELING ARE SUBJECT TO THE FOLLOWING: 1. Immediate suspension from all athletic related activities, in addition a two-week suspension after the sample is provided.

7 2. Second failure to report for testing or counseling will result in an immediate suspension as well as 30 days after a sample is provided. *** Special circumstances will be considered for failure to show for testing or counseling POSITIVE TEST RESULTS: Prohibited banned substances: Any prohibited drug/substance found in Article of the NCAA Constitution and Bylaws, or any violation of Article of the NCAA Constitution and Bylaws, as amended from time to time (the Banned Drugs ), regardless of whether such Banned Drugs are prescribed or non-prescribed, legal or illegal, and any other controlled dangerous substance, may be tested for by St. John s Athletics and/or by the NCAA. Included among those substances to be tested, without limitation, are amphetamines, cocaine, tetrahydrocannobinol (THC or marijuana) and anabolic steroids. In addition, each studentathlete may be subject to testing for the presence of any other drug prohibited by the NCAA or for the presence of any other controlled dangerous substance. Testing for the presence of Banned Drugs/Substances by the NCAA shall be in addition to, and not in place of, any testing done by St. John s University. A copy of the Banned Drug list will be provided at the start of the year compliance meeting as well available for inspection and review in the Training Room. ATHLETIC DEPARTMENT SANCTIONS ON POSITIVE TESTS: A University Drug Violation counts as a positive test. And depending on the violation, may lead to immediate suspension and revocation of grant-in-aid. First Positive Test 1. Director of Sports Medicine will notify student-athlete, University Physician, Athletic Director, and Head Coach within 24 hours of a positive test result. 2. The University Physician will evaluate the test results and may recommend immediate suspension for any health related issues. 3. The Director of Sports Medicine will arrange for the student-athlete to meet with the University Physician, and the University Drug Counseling Center. 4. The University Physician will contact the parents or legal guardian of the studentathlete within 72 hours unless circumstances prohibit 5. Student-athlete is required to attend 3 scheduled meetings with the member of the University Drug Counseling Center. The counselor will determine if additional meetings are necessary, either in or out patient. 6. Mandatory re-testing is to be performed monthly, year-round for the remainder of the student-athlete s career, or as deemed necessary by the counseling consultant of athletes and the Physician. 7. The Director of Sports Medicine will educate the student-athletes regarding the sanctions as well as future penalties associated to each positive test result. 8. Student-athlete may be subject to team suspension and/or disciplinary action which may include the loss of athletic related grant-in-aid at the discretion of the Head Coach. 9. In extraordinary circumstances, as determined by the Athletic Director a first violation may result in one or more of the following: a) Suspension-temporary, indefinite or permanent suspension of the studentathlete from further participation in all intercollegiate athletic programs. b) Cancellation of all or part of athletic grant-in-aid.

8 Second Positive Test 1-9. Steps 1-9 are the same as a 1 st Positive Test (see above) 10. Suspension: Minimum of 2 weeks suspension from all athletic related activities including practice and competitions (not to occur during pre-season or non-tradition season) Third Positive Test: 1. Director of Sports Medicine will notify student-athlete, University Physician, Athletic Director, and Head Coach within 24 hours of a positive test result. 2. Director of Sports Medicine will arrange for the student-athlete to meet with University Physician, the Athletic Director or his designee, Head Coach and Parents or legal guardian of the student-athlete. 3. Suspension: 12 month suspension of athletic related activity and LOSS OF ATHLETIC SCHOLARSHIP. 4. The student-athlete may petition the Athletic Director for reinstatement after successful completion of an approved drug counseling program. Monthly progress notes must be forwarded to Sports Medicine POST SEASON DRUG TESTING POLICY: 1. Sports Medicine Staff may test ALL members of a team or individuals who may qualify for Big East/NCAA post-season competitions.

9 Department of Athletics Authorization for Use and Disclosure Of Protected Health Information Name of student athlete: 1. I authorize St. John s University Department of Intercollegiate Athletics to use and disclose my protected health information for purposes relating to my participation in athletic activities. My protected health information may be disclosed to coaching staff, Department of Athletics staff, and officials of St. John s University in relation to my participation in athletic activities. 2. I also authorize St. John s University to disclose protected health information relating to my participation in athletic activities to the following: (initial all that apply) News Media Professional Scouts & Teams STJ Counseling Services Parents/Guardian other medical providers Limitations, exceptions, or restrictions on disclosure (optional): This authorization expires one year from the date of signature, unless a different expiration date or event is specified below. Comments(optional): Acknowledgements: This authorization may be revoked in writing at any time, in whole or in part, except to the extent that St. John s University has already disclosed information in reliant upon it. Signing this authorization is not a condition for treatment, payment, enrollment, or eligibility for benefits. I understand that if this authorization allows my protected health information to be disclosed to a recipient that is not a health care provider or a health plan, the information disclosed may no longer be confidential. Signature Date signed: If this authorization is signed by a personal representative of the student-athlete, the representative s authority to act on behalf of the student-athlete is: parent guardian.

10 DEPARTMENT OF ATHLETICS NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In the course of its activities, the St. John s University Department of Athletics (the Department ) obtains, creates, uses, and discloses health-related information about you. You have certain rights relating to the privacy of some of that information, and the Department of Athletics has corresponding obligations. All members of the Department who are involved in providing health care or handling health care records are required to follow this Notice, including health care providers who need to review your record in order to provide services to you, and students or trainees that we allow to participate in your care. This Notice applies to records that the Department of Athletics creates or keeps relating to your health care and treatment, such as treatment records and billing records, whether on paper or in a computer system, if you are identifiable in those records ( protected health information ). WAYS IN WHICH YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED The following categories describe ways in which the Department may use and disclose protected health information without your written authorization. This list includes some examples, but does not include every possible situation. Treatment. The Department may use protected health information to provide you with health care treatment and services. We may disclose protected health information about you to physicians, athletic trainers, or other personnel who are involved in your treatment in the Department. We may also disclose protected health information about you to health care providers outside of the Department who are involved in your health care or treatment. For example, in the event that an injury occurs out of town, we may disclose your protected health information to athletic trainers and physicians from other schools who are acting in place of Department members. We may also share information with your physician or with other health care providers in order to coordinate services, such as lab work and x-rays. Payment. The Department may use and disclose protected health information in order to bill and collect payment for the health care services and items you receive. For example, we may contact your health insurer to certify that you are eligible for benefits, and we may need to disclose protected health information to your health insurer in order to obtain payment for services, to obtain prior approval, or to determine whether your plan will cover the treatment or service. Health Care Operations. We may use and disclose protected health information in order to conduct our normal health care operations. For example, we may use your protected health information to review the treatment and services provided, to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide for you. We may also disclose protected health information to other companies that perform business services for us, such as software vendors, attorneys, or auditors. In those situations, we will have a written agreement with those other companies to ensure that they will protect the privacy of your protected health information. Reminders and Follow-up Phone Calls. We may use and disclose protected health information to contact you with a reminder that you have an appointment for treatment. We may also call to follow up on care you received with us, to tell you of test results, or to confirm an appointment with another health care provider. Treatment Alternatives or Other Health-Related Benefits. We may use and disclose protected health information to tell you about possible treatment alternatives or health-related benefits or services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. Health professionals in the Department, using their professional judgment, may disclose protected health information to a family member, other relative, a close personal friend, or any other individual who is involved in your care or in payment for your care. Emergencies. the Department may use or disclose protected health information in emergency situations if there is no opportunity to object to such uses and disclosures because of your incapacity or an emergency treatment circumstance. As Required By Law. The Department will use or disclose protected health information to the extent that such use or disclosure is required by federal, state or local laws.

11 Public Health Risks. We may use or disclose protected health information to authorized public health officials so they may carry out public health activities. For example, we may disclose your protected health information to public health officials for the following reasons, in accordance with law: to prevent or control disease, injury or disability; to report vital events such as births and deaths; or in relation to quality, safety or effectiveness of FDA-regulated products or activities. To Avert Serious Threat to Health or Safety. The Department may use or disclose protected health information if, in good faith, we believe that it is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, and the disclosure is to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat; or it is necessary for law enforcement authorities to identify or apprehend an individual. Workers' Compensation. The Department may, in accordance with law, disclose protected health information for workers' compensation or other similar programs that provide benefits for work-related injuries or illnesses. Lawsuits and Legal Proceedings. The Department may use or disclose your protected health information in response to a court or administrative agency order, if you are involved in a lawsuit or similar proceeding. We also may disclose your protected health information in response to a subpoena or other lawful process by another party involved in the dispute, but only if we have received satisfactory assurances from the party requesting the information that reasonable efforts have been made to inform you of the request, or a qualified protective order has been obtained. Law Enforcement Purposes. The Department may disclose your protected health information to law enforcement officials reasons such as the following: in response to court orders, warrants, subpoenas, or similar legal process; to assist law enforcement officials with identifying or locating a suspect, fugitive, material witness, or missing person; if you have been or are suspected of being a victim of a crime and you agree to the disclosure, or if we are unable to obtain your agreement because of incapacity or other emergency. if we suspect that a death resulted from criminal conduct; to report evidence of criminal conduct that occurred on the premises of the Department; to report a crime, including the location or victims of the crime, or the identity, description or location of the person who committed the crime. Specialized Government Functions. The Department may use and disclose protected health information regarding: military and veteran activities; intelligence, counter-intelligence, and other national security activities authorized by law; or protective services for the President, to foreign heads of state, or to other persons authorized by law Coroners, Medical Examiners and Funeral Directors. The Department may disclose protected health information to a coroner, a medical examiner, or a funeral director as necessary to carry out their duties. Research. In most cases, we will ask for your written authorization before using or disclosing your protected health information to conduct research. However, in limited circumstances we may use or disclose protected health information without authorization if: the use or disclosure was approved by an Institutional Review Board or a Privacy Board, and we obtain appropriate assurances from the researcher that the information is necessary for the research protocol, protected health information will not be removed from the Department, and the information will be used solely for research purposes; or the protected health information sought by the researcher relates only to decedents and the researcher agrees that the use or disclosure is necessary for the research. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION Right to Inspect and Copy. You have the right to inspect and receive a copy of your protected health information, including information maintained in our treatment and billing records. If you request a copy of your protected health information, we may charge a fee for the costs of copying. Under certain circumstances, we may deny your request to inspect or obtain a copy of your protected health information. If your request for inspection is denied, we will provide you with a written notice explaining our reasons for such denial, and will include a description of your rights to have the decision reviewed and how you can exercise those rights. Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask the Department to amend the information. To request an amendment, your request must be made in writing and should include the reasons(s) why you believe we should amend your information. We will respond to your request for amendment no later than 60 days after the receipt of your request. If we deny your request for an amendment we will provide you with a written notice that explains our reasons. You will have the right to submit a written statement disagreeing with our denial. You will also be informed of how to file a complaint with us or with the Secretary of the Department of Health and Human Services

12 Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." An accounting of disclosures is a list of disclosures the Department has made of your protected health information, except for the following: Disclosures to carry out treatment, payment, and health care operations; Disclosures made to you; Disclosures in accordance with an authorization you signed; Disclosures made in a facility directory or to persons involved in your care; Disclosures for national security or intelligence purposes; Disclosures to correctional institutions or law enforcement officials; or Disclosures made before April 14, To request an accounting of disclosures, you must submit your request in writing and must state the time period for which you are requesting an accounting of disclosures, which may not be longer than six years and may not include dates before April 14, The first list you request will be free. If you request additional lists within 12 months, we will charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before costs are incurred. We will respond to your request for an accounting of disclosures within 60 days. Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will limit the disclosure of your protected health information unless the information is needed to provide you with emergency treatment or to comply with law. To request restrictions on disclosures, you must make your request in writing, and you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you have the right to request that messages not be left on an answering machine. To request confidential communications, you must make your request in writing. We will not ask you the reason for your request, and we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and how payment for your health care will be handled if we communicate with you through this alternative method or location. Right to Receive a Paper Copy of This Notice. You have the right to request a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this Notice, please ask any staff member. CHANGES TO THIS NOTICE The Department reserves the right to revise the terms of this Notice of Privacy Practice. Any changes to this Notice will be effective for all records that the Department has created or maintained in the past, and for any of your records that we may create or maintain in the future. If we make any changes to our Notice of Privacy Practices, the revised notice will be available to you on request. If we make a major change in this Notice that affect the use and disclosure of your protected health information, your rights, our duties, or our privacy practices, you will be informed in accordance with law. In addition, a copy of our current Notice of Privacy Practice is posted in a visible location at the Department at all times. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the St. John s University Privacy Official, or with the Department and with the Secretary of the Department of Health and Human Services. To file a complaint with the Department, contact the Privacy Official at the address shown below. Submitting a complaint to the Privacy Official or to the Secretary of the Department of Health and Human Services will not affect your status as a recipient of treatment in the Department, and the Department will not penalize you for filing a complaint. FOR FURTHER INFORMATION If you have any questions about this Notice of Privacy Practice, you may contact the Privacy Official at St. John s University, 8000 Utopia Parkway, Queens, New York, 11439, Effective Date: April 14, 2003

13 ATTENTION: **Those People Participating in an HMO or other Managed Health Care Plan** If you belong to an HMO insurance coverage plan, or other managed care plan, you should contact your employer s benefits provider or your insurance company before your child enters school this Fall. If you are unsure of the nature of your medical insurance coverage, contact your employer s benefits provider or insurance company to clarify your coverage. It has been our experience that it would be beneficial for you to contact your insurance company NOW, long before your child enters school in the Fall, to ask the appropriate questions in order to maximize your benefits, and to ensure your child has adequate, hassle-free coverage while he/she is away at school. You may find it necessary for you to change insurance coverage if your insurance company will not allow out-of-network coverage for your child. If you have any printed material or phone numbers that should be called prior to the student athlete receiving any medical treatment that would assist in this matter, please include them when you return this form along with the insurance information & demographic form. This worksheet is designed for you to use when you call your insurance company. Use the blank lines to answer the questions. Please return this form (filled out) to us once you are finished, along with the insurance questionnaire. 1. Can we set up out-of-network coverage for my child while he/she is away at school? YES NO 2. What providers in the New York City area are acceptable for my child to see in the event he/she has an injury/illness? (This is once out-of-network coverage is set up) 3. Does my child need to be certified as a full-time college student to be covered (while away at school)? If yes, will you send the appropriate paperwork? YES NO 4. Are there specific guidelines that must be followed in order to access medical care (out-of-network care) while my child is away at school at St. John s University?

14 St. John s University Student Athlete Insurance and Demographic Information Student Athlete s Name Date of Birth STJ ID# Sport Cell Phone Home Phone Emergency Contact Name Emergency Contact Phone# PARENT/GUARDIAN DEMOGRAPHIC INFORMATION Father/Guardian Mother/Guardian Name Name Address Address City State Zip City State Zip Date of Birth Date of Birth Employer Employer Home Phone Work Phone Home Phone Work Phone PRIMARY INSURANCE INFORMATION: INCLUDE FRONT AND BACK COPY OF INSURANCE CARD Subscriber s Name _ Group Number Identification Number _ Insurance Company _ Insurance Company Mailing Address Insurance Company City, State, and Zip Insurance Company Phone Primary Care Physician (PCP) Name PCP Address PCP City, State, and Zip PCP Phone

15 SECONDARY INSURANCE INFORMATION: INCLUDE FRONT AND BACK COPY OF INSURANCE CARD Subscriber s Name _ Group Number Identification Number _ Insurance Company _ Insurance Company Mailing Address Insurance Company City, State, and Zip Insurance Company Phone Primary Care Physician (PCP) Name PCP Address PCP City, State, and Zip PCP Phone PRESCRIPTION PLAN INFORMATION: INCLUDE THE FRONT AND BACK COPY OF INSURANCE CARD Group Number Identification Number Insurance Company Insurance Company Address Insurance Company City, State, ZIP Insurance Company Phone DENTAL INSURANCE INFORMATION:INCLUDE THE FRONT AND BACK OF INSURANCE CARD Group Number Identification Number Insurance Company Insurance Company Mailing Address Insurance Company City, State, ZIP Insurance Company Phone STUDENT ATHLETE SIGNATURE: ALL STUDENT ATHLETES ARE REQUIRED TO SIGN THIS SECTION I certify that, to the best of my knowledge, the information I have provided is complete and correct. I will promptly inform the Sports Medicine office of any changes of insurance coverage or demographic information. Signature Date ** Please include enlarged copies (front & back) of all insurance cards**

16 St. John s University Athletic Department Insurance Information Pamphlet Welcome! We hope the information in this pamphlet helps to explain our athletic insurance policy, referral procedures, and answer any questions you may have concerning the scope of coverage. We look forward to having your child represent The Red Storm. **What type of athletic insurance does the athletic department carry? Our goal is to provide the best possible health care for our student athlete. To achieve this goal, communication and cooperation between the attending physician and our Sports Medicine Network are essential from the time of injury through complete rehabilitation. Your cooperation in adhering to the policies and procedures outlined in this pamphlet will enhance care and is necessary to make claims against our insurance. As a service to our student athletes, the Athletic Department provides a secondary or supplemental athletic accidental insurance. The secondary policy will only be applied to medical costs incurred for services rendered by a participant in the St. John s University Sports Medicine Network and their specific written referral for further care. That care must still be coordinated through the Sports Medicine Staff prior to the visit. The secondary policy is applicable only for athletic injuries that are a direct result of intercollegiate accidents during a required St John s University practice or competition supervised by a coach. The secondary insurance policy requires that the injured athlete first make a claim under their primary medical or hospitalization insurance. Medical expenses not covered by the primary insurance will be paid under the school s policy (subject to its limitations and conditions). Although we attempt to purchase the most comprehensive policy within our resources, this is not an all-inclusive policy. **How does my child qualify for secondary coverage? You must complete an annual medical Insurance Information and Demographic Form that asks for the personal insurance information under which your child is covered. This form, along with a photocopy of the applicable primary medical insurance I.D. card (front and back), must be on file in the athletic training room prior to an injury. **How does the insurance coverage work? The secondary insurance policy requires that the injured athlete first make a claim under the primary insurance. We send your primary insurance information when the athlete is referred for care. The provider should file a claim with your insurance company for the services rendered. Your company will evaluate the claim and either pay you or the provider directly or deny the

17 claim. If the provider does not file with the primary insurance, the provider may send you a bill for you to file with your insurance company. If after 60 days of the date of injury, you have not received anything form your insurance company: 1. Call your insurance company to check the status of the claim, and/or 2. Submit the bill from the provider to your insurance company. We will also send the providers our secondary insurance information and notify our insurance company that a claim may be forthcoming. The provider should file a claim against our secondary insurance company after your primary insurance has been exhausted. * You should contact the providers directly to make sure they have filed with primary and secondary insurance companies. You may need to file these claims yourself. **When is an athlete referred to a physician? Whenever the team physicians or the athletic trainers are of the opinion that a consultation would facilitate/improve the care of an injury, arrangements for such a visit will be made. Coaches do not have the authority to refer an athlete to any physician except for emergency medical care when the Sports Medicine Staff is not available. **What if I belong to an HMO? If you belong to a Health Maintenance Organization (HMO), you are limited to the HMO s physician and facilities. You are requested to send us specific instructions, requirements, and/or limitations, which may be included with the policy. This information is necessary for the claims process to be filed correctly. Failure to follow the proper HMO procedures will void your eligibility for coverage under the athletic department s secondary insurance. **Which physicians can an athlete see under the secondary insurance plan? For an athlete to be covered under the athletic department s secondary insurance, they may be seen only by participants in our Sports Medicine Network. This network is composed of a wide range of specialists from the local medical community. This group is dedicated to providing the best possible health care to St. John s University athletes. We formed this network to insure accurate and continuous communication between the physicians and the Sports Medicine Staff. Prior written authorization must be if an athlete wishes to seek medical attention outside of the network. Authorization is granted only in cases where our consulting physicians cannot provide the required care. If an athlete seeks a second opinion or care from an out-of-network provider, he/she will be medically ineligible to participate in athletics or utilize the service of the St. John s University Sports Medicine Program until medical records are received and reviewed by the Sports Medicine Staff. The athlete has the responsibility to see that the physician forwards all requested information. You also assume the financial responsibility for any travel cost and the services of that provider. Our secondary insurance cannot be applied to those services. **Towards which bills can the secondary insurance coverage be applied? The athletic department s secondary insurance can be applied only to those bills for an athletic injury:

18 1. when prior approval for a referral was granted through the Sports Medicine Staff, 2. when the care has been coordinated through the Sports Medicine Staff, 3. for services rendered by participants in the Sports Medicine Network and their specific written referral, 4. for care rendered within 52 weeks of the date of injury, and 5. your insurance company has responded to and resolved all claims **What types of things are NOT covered under secondary insurance? Any injury sustained outside of an NCAA sanctioned practice or competition supervised by a coach will not be covered. Examples include summer outside competition, voluntary captain practices, voluntary summer workouts, and voluntary training sessions. A chronic injury or recurrent injury that was sustained prior to participation in athletics at St. John s University. Any degenerative conditions diagnosed by a physician. Any illness (cold, flu, infection, etc) Unauthorized consultations or treatments. Conditions as a result of non-compliance with school s policies, team rules, or the advice of the team physician, attending physicians, the certified athletic trainers, or coach. Any injury that is not reported to the Sports Medicine Staff within the 7 days of occurrence or onset of symptoms. **What are the parent s and/or athlete s responsibilities? It must be clearly understood that the parents and the athlete are responsible for maintaining proper health coverage and prompt submission of all claims and bills to their insurance company. The Athletic Department of St. John s University will not be responsible for medical expenses that were not properly processed by athletes and parents to their primary carrier. **Please keep this form so you may refer to it if and when any insurance questions or situations arise**

19 Sports Medicine Sickle Cell Trait Information Form The NCAA recommends that all student-athletes be aware of their sickle cell status. If the student athlete does not know whether they are positive for sickle cell trait, the NCAA recommends that student athletes undergo testing to determine their status. St. John s University is supportive of this recommendation and requests that each student-athlete provide Sports Medicine with documentation of their sickle cell trait status. If a student opts not to provide the University with this information, s/he must sign the testing waiver below. To help you make an informed decision regarding this issue, some basic information is provided below, as well as a link to additional resources. About Sickle Cell Trait- Sickle cell trait is an inherited condition of the oxygen-carrying protein, hemoglobin, in the red blood cells. Sickle cell trait is a common condition, which affects more than 3 million Americans Although sickle cell trait is most predominant in African-Americans and those of Mediterranean, Middle Eastern, Indian, Caribbean, and South and Central American ancestry, persons of all races and ancestry may test positive for sickle cell trait. Sickle cell trait is usually benign, but during intense, sustained exercise, hypoxia (lack of oxygen) in the muscles may cause sickling of red blood cells (red blood cells changing from a normal disc shape to a crescent or sickle shape), which can accumulate in the bloodstream and logjam blood vessels, leading to collapse and even death due to the rapid breakdown of muscles starved of blood. More information regarding sickle cell trait and the rationale for the NCAA s recommendation that all student athletes be aware of their status may be found at Sickle Cell Trait Testing- St. John s University offers sickle cell trait screening in the form of a blood test to all student-athletes. Testing can be conducted at the offices of Dr. Osric King or other laboratory facility of the student s choosing. To arrange for testing at Dr. Kings office, please call (718) or see your athletic trainer. If you choose to undergo testing, all costs associated will be processed through our compliance office. Please attach results to this form and return both with your physical paperwork.

20 Sports Medicine Sickle Cell Trait Waiver Form I, understand and acknowledge that the NCAA and St. John s University recommends that all student-athletes have knowledge of their sickle cell trait status. Additionally, I have read and fully understand the aforementioned facts about sickle cell trait and sickle cell trait testing. Recognizing that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries, ailments, and/or disabilities experienced, I hereby affirm that I have fully disclosed in writing any prior medical history and/or knowledge of sickle cell trait status to St. John s University Sports Medicine personnel. By signing this waiver, I confirm that I do not wish to undergo sickle cell trait testing as part of my pre-participation physical examination and I voluntarily agree to release, discharge, indemnify and hold harmless St. John s 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 my decision not to follow the recommendation that I be aware of my sickle cell trait status and share that information with the St. John s Sports Medicine Department. Student-Athlete Name: Date: I have previously undergone sickle cell trait testing Date of test: Results of testing: Yes, I have sickle cell trait No, I do not have sickle cell trait Student-Athlete Name: Date: By signing this waiver, I confirm that I do wish to undergo sickle cell trait testing as part of my pre-participation physical examination so that I may be aware of my sickle cell trait status and share that information with the St. John s Sports medicine Department. Student-Athlete Name: Date: I have read and signed this document with full knowledge of its significance. I further state that I am at least 18 years of age and competent to sign this waiver. Student-Athlete Signature: Date: Parent/Guardian Signature (if under 18 years of age): Parent/Guardian Print Name: Date:

21 STUDENT-ATHLETE INITIAL HEALTH HISTORY Name: Date of Birth: Last First Middle Sport: Local Address: Home Address: Cell Phone: Street City State Zip Street City State Zip Home Phone: Address: If transfer student, name and location of previous college: Please read carefully and answer ALL questions about ALL injuries in appropriate section. 1) Have you had any history of concussion or being knocked unconscious? 2) Have you had any history of neck injuries? 3) Have you had any history of burners, stingers, numbness or weakness in your neck, shoulders, arms, or hands? Right or Left (circle one) 4) Have you had any history of back injury(s) or back pain? 5) Have you ever been diagnosed as having scoliosis? Yes No Date 6) Have you ever had a shoulder injury? If yes, read and complete below. (a) Shoulder dislocation or subluxation: (b) Shoulder separation: (c) Rotator cuff injury (i.e. tendinitis, partial or complete tear: 7) Have you ever had a knee injury? If yes, read and complete below. (a) Meniscus (cartilage) - Medial (inside) or lateral (outside): (b) Ligament sprain - MCL, LCL, ACL, PCL: (c) Tendonitis, bursitis, chondromalacia, or patellofemoral problems: (d) Dislocated, subluxed, or fractured knee cap (patella): (e) Do you wear a prescribed knee brace? 8) Have you ever had a lower leg injury? If yes, read and complete below. (a) Ankle sprain(s) - Medial (inside) or Lateral (outside): (b) Achilles tendon injuries: If yes, explain injury. Type of injury (i.e. tendonitis, tear): (c) Ankle or lower leg fracture: If yes, explain fracture. Type of fracture: 9) Have you had a foot injury? If yes, explain injury. Type of injury: Do you wear prescribed corrective orthotics? If yes please explain reason: 10) Have you had a thigh/hip injury? If yes, explain injury. Type of injury (i.e. strain, sprain, dislocation): 11) Have you had a wrist/hand injury? If yes, explain injury. Type of injury: 12) Have you had an elbow injury? If yes, explain injury. Type of injury: 13) Have you had an arm injury? If yes, explain injury. Type of injury: 14) Have you ever required surgery for any medical illness/condition? If yes, explain illness/condition and surgical procedure: Right or Left Yes No Date 15) Have you been found to have only one of the two (paired) functioning organs? Yes No (a) Eyes: If yes, which one is missing? Right Left (b) Kidneys: If yes, which one is missing? Right Left (c) Testicles: If yes, which one is missing? Right Left (d) Ovaries: If yes, which one is missing? Right Left

22 16) Do you require medication on a daily or episodic routine? (i.e. daily insulin or asthma medication) If yes, list medications: Taken how often: List medical condition: 17) Do you have an allergy to food, stinging insects or drug medications? If yes, list allergies: Explain symptoms of allergic reaction: Explain usual course of treatment: Yes Yes No No 18) Have you ever been diagnosed or had problems with: Yes No (a) Heart murmurs: (b) Epilepsy: (c) Asthma: (d) Diabetes: (e) Kidney disease: (f) Hernia: (g) Mononucleosis: (h) Anemia: (i) Menstrual problems or irregularities: **If you answered yes to any of the above questions, briefly describe specific condition and any previous and/or current treatment(s) on the last page. Please number each explanation with the corresponding the question. 19) Do you normally wear eye corrective lenses while participating in sports? If yes, do you normally wear glasses or contact lenses? (circle one) Contact lens type: 20) Do you have any other medical illness or injury, past or present that we should know about for your own protection? If yes, please explain: 21) Have you ever been examined and /or tested for ADHD at your elementary, middle school, high school or by a private physician? 22) Are you presently taking any medications for ADHD? If yes, what is the medication? 23) Have you ever had a MRI, CT Scan, Bone Scan or any other diagnostic test in the last 5 years? If yes, please explain reason: 24) Have you been to an Emergency Room or visited a physician for any reason OTHER than for routine physicals? If yes, please explain Yes No If you answered yes to any of the above questions regarding injuries, please indicate the type of injury; where the injury occurred; the cause of the injury; the type of treatment given, if any; and whether or not surgery was performed, including the date of the procedure. (Please use this page to explain any injuries). I certify that, to the best of my knowledge, the information I have provided is complete and correct. I have made a full and complete disclosure to St. John s University Sports Medicine of all of my present or prior physical or mental defects, illnesses, injuries or conditions known to me. Athlete signature: Parents signature: Date: Date:

23 Medical Records (Please retain a copy for your files.) Please complete and fax, mail, or return in person to the Health Services Center at the Queens campus. Please print. Name: Address: Student Health Services Queens Campus 8000 Utopia Parkway Queens, NY Tel Fax stjohns.edu Date of Birth: Home Tel: Student X #: Emergency Contact Name: Tel: Campus where you are enrolled: (check one) Queens Manhattan Staten Island Medical History (Include dates if possible) Allergy Drugs: Allergy Foods: Heart Disease: Diabetes: Hypertension: Hypoglycemia: Allergy Other: Kidney Disease: Chicken Pox: Asthma: Seizure Disorder: Other: Have you had any serious accidents? Yes No Nature of injury: List of operations and dates: Do you take prescribed medications on a regular basis? Yes No If yes, please list: Do you have a physical, learning, or other disability of which the University should be aware in order to help you achieve your educational goals? Yes No If yes, please describe: He, alth insurance is MANDATORY for all resident and international students. CONSENT FOR MEDICAL TREATMENT: The law requires that parental permission be obtained so that medical treatment can be administered to students under the age of 18. I hereby grant permission for medical evaluation, treatment and/or hospitalization in case of illness or accident for myself/son/daughter/guardian. I grant permission for hospital admission and for administration of anesthetics and necessary operative procedures in an emergency. I give permission for the release of information concerning my/his/her medical condition to other responsible University officials when necessary. Name of Student: Student X #: Signature of Parent/Guardian: Date: Tel:

24 Physical Examination (To be completed by physician or health care provider.) Please complete and fax, mail, or return in person to the Health Services Center at the Queens campus. Student Health Services Queens Campus 8000 Utopia Parkway Queens, NY Tel Fax stjohns.edu Student Name: Student X#: Date of Birth: Gender: Male Female Campus where you are enrolled: (check one) Queens Manhattan Staten Island Height: Weight: Blood Pressure: Pulse: Vision: Right: Left: Corrected: Right: Left: For Health Sciences Students only: Color Vision Screening Normal Urinalysis Result Normal Blood Count HCT: Head, neck, face, and scalp Nose and sinuses Mouth, teeth, gingival Ears Eyes Lungs, chest, and breasts Heart Vascular Abnormal Abnormal HGB: Date: Date: Normal Abnormal Normal Abnormal Abdomen Endocrine System Extremities Reflexes Musculoskeletal Lymphatic Neurologic Genital/Urinary In your judgment, is there any reason why physical activities would be contradicted? Yes No If yes, explain Family history (relevant health problems) TB SCREENING Tuberculin Skin Test (within six months of exam): Date Planted / / Result: Positive Negative mm induration Date Read / / PharmacyD Students Only two step testing necessary: Date Planted / / Date Read / / Result: Positive Negative mm induration or QTF TB Gold Test Date / / Result: Positive Negative Attach QTF Lab Results *If QTF or PPD Test Positive, Chest X-Ray Required: Date / / Result: Positive Negative The information contained on this form is accessible only to the professional health staff of the Student Health Services and will not be released without the written authorization of the student or pursuant to a lawfully issued subpoena. The authority to request this information is found in Section 355 of the Educational Law. VACCINE RECORD- if blood titers drawn, please attach lab results Tetanus-Diphtheria Booster: (within 10 years) Date / / Tdap Date / / Varicella Vaccine: Dose 1 / / Dose 2 / / or Disease Date / / Hepatitis B Vaccine (recommended): Dose 1 / / Dose 2 / / Dose 3 / / Meningococcal Vaccine (recommended after 16th birthday): Date / / or Refused Attach Meningitis Response Form MMR (required by NYS Law): Dose 1 / / Polio series completed: Yes No Dose 2 / / Physician s Name (Print) Signature: Exam Date / / License Number: or attach Rx with signature Physician Stamp: