Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet.

Transcription

1 Due Dates: Incoming Fall Students July 15 th Incoming Spring Students December 15 th Incoming Summer Students July 15 th THESE FOLLOWING ARE REQUIRED BY NJ STATE LAW AND ROWAN UNIVERSITY POLICY. FAILURE TO COMPLETE THE FOLLOWING 3 STEPS MAY RESULT IN UP TO $100 IN LATE FEES & A HOLD PLACED ON YOUR ACCOUNT, PREVENTING FUTURE REGISTRATION. 1 Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet. 2 Complete Online Medical History Forms through OWL (Online Wellness Link). 3 Upload your Provider Packet to OWL prior to the due date. Important Reminders: Students should carry health insurance & prescription cards with them at all times. It is a student s responsibility to check their Rowan Student account frequently for important notices. We also use this account to notify students of any issues/deficiencies with the forms they have submitted.

2 Due Dates: Incoming Fall Students July 15 th Incoming Spring Students December 15 th Incoming Summer Students July 15 th STEP 1: Print Provider Packet & Schedule Appointment A. Go to and select the Mandatory Pre-Entrance Health Forms tab. Click on the Provider Packet link and print it. B. Schedule an appointment with your healthcare provider. Take your Provider Packet to your appointment to have your healthcare provider complete. Also, talk to your provider about any chronic conditions you may have and how you can be prepare to deal with these conditions when you are at school. STEP 2: Complete Online Medical History Forms A. Go to to access the Online Wellness Link (OWL). Having trouble with your username or password? Go to B. Select FORMS from the menu on the left. Complete and submit each of the four forms one time each. C. Check Yourself: You should notice a submit date next to each form once they have been completed. STEP 3: Upload your completed Provider Packet to OWL Make sure your name, date of birth, and student ID# are on all forms. Physicals should be signed and dated. Scan and save your documents into separate files in the below categories. Make sure your file is in one of the following acceptable formats:.gif,.png,.tiff,.tif,.jpg,.jpeg,.txt or.pdf. Do not use any special characters in your file name. Immunizations Record (Provider Packet Page 3 of 6) and any additional immunization records Entrance Physical Form (Provider Packet Page 4 of 6) TB Evaluation and Testing Form (Provider Packet Page 5 of 6) Titer Lab Reports/ Other Labs (Titer or any other lab reports) Consent for Treatment (Provider Packet Page 6 of 6 for any student under 18 years of age) Log into OWL using the instructions from STEP 2A above. Select UPLOAD DOCUMENTS from the menu on the left. A. Under Choose Document select the type of file to be uploaded. B. Click Browse to search for the scanned document. C. Click Attach. D. Repeat Steps 3A through 3C until all files have been attached. E. Click Upload. F. Check Yourself: Each file you uploaded should now have an upload date next to it. If there is no upload date, we have not received your file(s). Need Help? Visit for more information.

3 Due Dates: Incoming Fall & Summer Students July 15 th, Incoming Spring Students December 15th Last Name First Name M.I. Student ID# Date of Birth: M / D / Y IMMUNIZATIONS MEASLES, MUMPS, RUBELLA (MMR) 2 doses of vaccine administered after 1968, on or after 12 months of age, and at least 28 days apart are required OR laboratory proof of immunity. Copy of Measles (Rubeola), Mumps, and Rubella Virus IgG Antibody laboratory titer report must be attached if submitting in lieu of immunization dates. EQUIVICAL RESULTS NOT ACCEPTABLE. MMR Dose 1: / / MEASLES : Dose 1: / / ATTACH MEASLES IgG Titer Lab Report showing immunity REQUIRED FOR: ALL STUDENTS born AFTER 1956 OR MUMPS : Dose 1: / / OR ATTACH MUMPS IgG Titer Lab Report showing immunity MMR RUBELLA : Dose 1: / / ATTACH RUBELLA IgG Titer Lab Report showing immunity HEPATITIS B - In lieu of immunization dates a copy of a Hepatitis B laboratory titer report showing evidence of immunity may be submitted. HEPATITIS B vaccine HEPATITIS B vaccine HEPATITIS A and B two dose regimen combined Dose 1: / / administered at age Dose 1: / / years of age. HEPATITS B IgG Titer Lab Report showing Dose 1: / / immunity Dose 3: / / Dose 3: / / SELECT START STUDENTS ALL FULL-TIME STUDENTS - taking 12 or more credit hours ALL ATHLETES MENINGOCOCCAL MENINGITIS VACCINATION administered on or after 16 th birthday or within 5 years of the start of classes. Must include Groups A, C, Y, W-135. BOOSTER DOSE required if meningococcal vaccination administered more than 5 years prior to the start of classes. MENINGOCOCCAL of A, C, Y,W-135 Dose 1: / / MENINGOCOCCAL of B (Highly Recommended) Dose 1: / / Dose 3: / / ALL STUDENTS RESIDING IN CAMPUS HOUSING must be received prior to move-in ALL ATHLETES TETANUS Booster in the last 10 years. Tdap Td TT ALL ATHLETES In addition to the above immunizations the following are highly recommended. Varicella Hepatitis A Pneumococcal Polio Dose 1: / / Dose 1: / / HPV Dose 1: / / Dose 3: / / Physician/PA/NP Address: Phone: Physician/PA/NP Signature: Fax: Date:

4 Due Dates: Incoming Fall & Summer Students July 15 th, Incoming Spring Students December 15th Last Name First Name M.I Student ID# Date of Birth: M / D / Y Gender NOTE TO STUDENT: This form is mandatory for all undergraduate, International, ESL and EOF students. The physical examination must be completed and signed by a physician, physician assistant or nurse practitioner within the past 12 months to be valid. Students planning to participate in NCAA Athletics or the Athletic Training program must have this form completed and on file with the Student Health Services prior to scheduling their Mandatory Pre-Participation Physical Examination. Please visit the Sports Physical page of Student Health Services website for complete information. Temp: Height: Pulse: Weight: Resp: BMI: BP: Visual Acuity Right 20/ Left 20/ Medical History Hospitalization/Surgery Allergies Medications Does this patient, to the best of your knowledge, have a current or past history, of significant chronic or acute medical, psychological, emotional or addiction issues? Yes No (If yes, please attach a summary to this form) Skin HEENT Neck/Thyroid/Lymph/Nodes Thorax/Lungs Cardiovascular Heart murmurs (if indicated, please enclose EKG or ECHO reports) Abdomen Breast/GYN or Genitalia/Hernia Musculoskeletal Neurological Assessment NORMAL ABNORMAL COMMENTS Is this student capable of participating in University physical education courses or tryouts for intercollegiate sports? Yes No Explain any exceptions: Required Tuberculosis Screening: Yes No 1. Does the student have signs and symptoms of active TB disease? 2. Is this student a member of a high-risk group, or is the student entering a health profession? 3. Is the student planning to participate in intercollegiate athletics? 4. Did the student answer yes to any questions on their TB Screening Form? If yes to any of the above, please complete the Tuberculosis Evaluation & Testing Form. A copy of this form is found in the Provider Packet or can be downloaded by visiting the Printable Medical Forms page of our website Required Tests for NCAA Athletes: Sickle Cell Solubility Test: (Attach Lab Results) Tuberculosis Evaluation & Testing Form (Page 5 of 6) Physician/PA/NP Address: Phone: Physician/PA/NP Signature: Fax: Date:

5 Due Dates: Incoming Fall & Summer Students July 15 th, Incoming Spring Students December 15 th Last Name First Name M.I Student ID# Date of Birth: M / D / Y Healthcare Provider: If you or your patient has indicated that he/she is at risk for tuberculosis. Please complete the following: 1. Does the student have signs or symptoms of active tuberculosis disease? No Proceed to #2 Yes Proceed with additional evaluation to exclude active tuberculosis disease including tuberculosis testing, chest x-ray, and sputum evaluation as indicated. 2. Has the student had a POSITIVE TB Test in the past? No Proceed to #3 Yes, the student had a Positive TB Test on: / / Proceed to #4. 3. Administer TB skin test (PPD). Only acceptable if tested within last 12 months. Date place, read, and result in mm must be included. Date Administered: / / Date Read (must be read within hours after test was administered): / / Negative Sign bottom and office stamp. Positive or 10mm Proceed to #4. Result: mm OR Order IGRA blood test. (T-Spot or Quantiferon) Only acceptable if tested within last 12 months. Negative Sign bottom and office stamp. ATTACH LAB REPORT Positive Proceed to #4. ATTACH LAB REPORT 4. Chest x-ray: Required if TB Test is positive. Date of chest x-ray / / ATTACH RADIOLOGIST S REPORT Result: Normal Abnormal 5. Treatment: (TREATMENT OF LATENT TB IS RECOMMENDED FOLLOWING POSITIVE TB TEST) Medication Length of Treatment Date Started Date Completed Not valid unless signed and stamped by a Physician, PA or NP. Print Name & Title Office Stamp Signature Date: Office Telephone

6 Due Dates: Incoming Fall & Summer Students July 15 th, Incoming Spring Students December 15 th Student Health Services The Wellness Center at Winans 201 Mullica Hill Road Glassboro, NJ Consent for Treatment CLIENT NAME STUDENT ID # ADDRESS CITY STATE, ZIP CODE DATE OF BIRTH ENTRANCE DATE PHONE Authorization of treatment statement I hereby authorize Rowan University Student Health Services staff and physicians to provide health care evaluations, treatment and other medical services as necessary and certify, to the best of my knowledge, that the information provided in my health record is complete and accurate. In case of emergency, I authorize Student Health Services to secure emergency medical treatment and/or surgery at a hospital if such treatment is deemed necessary. I authorize Rowan University Student Health Services staff and physicians to share any medical information with hospital or emergency medical personnel in the case of an emergency or subsequent treatment. I understand that the Health Services staff and affiliated health care providers, including counseling and psychological services staff, retain the privilege to consult with one another about clients for treatment and/ or training purposes. If you participate in group counseling or health education, as a member of that group, you will be expected to commit to maintaining the confidentiality of that group. This authorization will remain in effect as long as I am a student at Rowan University. I understand that in the event of serious illness or injury, my parents or legal guardian may be notified at the discretion of the Student Health Services staff. SIGNATURE OF CLIENT OR LEGAL REPRESENTATIVE DATE IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO CLIENT DATE