INFORMATION FOR GRADUATE STUDENTS REGARDING MEDICAL CARE

Transcription

1 INFORMATION FOR GRADUATE STUDENTS REGARDING MEDICAL CARE As a graduate student at Bucknell University, you have the option to utilize Bucknell Student Health (BSH) for your medical care and health education needs, or you may choose to continue receiving medical treatment from your family physician. If you choose to use BSH, the Incoming Undergraduate Medical Record Form must be completed in its entirety and returned to BSH prior to registration. The form and instructions are available online at (Student Information), in the offices of Graduate Studies, or at Bucknell Student Health. If you prefer to continue with your current health care provider, Bucknell requires: - Completed BSH Tuberculosis Screening Questionnaire. If any questions on the questionnaire are answered yes, then you must also provide a Required Tuberculosis (TB) Screening that has been completed and signed by a medical provider. - TDAP (Tetanus, Diphtheria and Pertussis) vaccine since August MMR (Measles/Mumps/Rubella) Two doses after age 12 months, given at least 28 days apart, and since Blood test reports indicating immunity are acceptable. - Meningitis vaccine received within since August 2012, or a signed waiver for the vaccine. The form for reporting these vaccines (Graduate/Non-Degree Students Medical Requirements for Admission form) is available online at (Student Information), in the Graduate Studies office, or at Bucknell Student Health. This document must be completed and returned to BSH prior to registration. Failure to comply with TB/TDAP/MMR/Meningitis requirements will prevent you from registering for and attending classes.

2 GRADUATE/NON-DEGREE STUDENTS COMPLETING AND RETURNING THIS FORM ARE REQUIREMENTS FOR ADMISSION Student Name (please print) BU ID No. Date of Birth Admitted as a (check one): Graduate Non-Degree Session (check one): Fall Spring Summer MMR (Measles/Mumps/Rubella) Two (2) doses after age 12 months, given at least 28 days apart, and since Blood test reports indicating immunity are acceptable please attached them to this form. MMR 1 st Dose Date: MMR 2 nd Dose Date: OR Blood test reports attached TDAP (Tetanus, Diphtheria and Pertussis) vaccine since August Vaccine date TUBERCULOSIS: A requirement for admission is completion of the attached TUBERCULOSIS SCREENING QUESTIONNAIRE. Part V Page 1 should be completed. Provider to complete and sign Part V Page 2 only if student answered Yes to Part V Section B. Part V Page 2 TST interpretation should be based on mm of induration as well as risk factors. MENINGITIS Please check the statement that applies and sign: I have received the meningitis vaccine (Serogroup A,C,Y,W135) since August Vaccine date. I have read and understand the information about meningitis, and I decline the meningitis vaccine or meningitis booster vaccine at this time. I understand that if I decide in the future that I want the vaccine, I can receive it at the Student Health Service and that I am responsible for the cost. Student signature or Parent signature if student is under 18 or not yet graduated from high school. Date I verify that all the above information is correct and that I have reviewed a copy of the Notice of Privacy Practices for Bucknell Student Health (copy enclosed). Student Signature Date Parent Signature required if student is under age 18 and not a high school graduate. Date Please complete this form and return it to: Bucknell Student Health, Bucknell University, Lewisburg, PA Telephone: Fax:

3 MENINGITIS INFORMATION College students are at increased risk for meningococcal disease, a potentially fatal bacterial infection commonly referred to as meningitis. In fact, first-year students living in residence halls are found to have a six-fold increased risk for the disease. The American College Health Association recommends that college students, particularly first-year students living in university housing, learn more about meningitis and vaccination. At least 70% of all cases of meningococcal disease in college students are vaccine preventable. On July 28, 2002, the Pennsylvania Governor signed legislation (Senate Bill 955) which requires that all students residing in university housing either have the vaccine or sign a declination statement after review of written information concerning the benefits of receiving the meningitis vaccine. What is meningococcal meningitis? Meningitis is rare. But when it strikes, this potentially fatal bacterial disease can lead to swelling of membranes surrounding the brain and spinal column as well as severe and permanent disabilities, such as hearing loss, brain damage, seizures, limb amputation, and even death. How is it spread? Meningococcal meningitis is spread through the air via respiratory secretions or close contact with an infected person. This can include coughing, sneezing, kissing or sharing items such as utensils, cigarettes and drinking glasses. What are the symptoms? Symptoms of meningococcal meningitis often resemble influenza and can include high fever, severe headache, stiff neck, rash, nausea, vomiting, lethargy, and confusion. Who is at risk? Certain college students, particularly first-year students who live in residence halls, have been found to have an increased risk for meningococcal meningitis. Can meningitis be prevented? Yes. A safe and effective vaccine is available to protect against Groups A, C, Y, and W-135, which account for 60 70% of all cases in the college age group; the vaccine does not protect against Group B, which accounts for 35 40% of illness in college students. To learn more about meningitis and the vaccine, visit Bucknell Student Health or call Information is also available on: o o The Centers for Disease Control and Prevention (CDC) website, The American College Health Association website,

4 Bucknell Student Health Tuberculosis (TB) Screening Questionnaire PAGE 1 TO BE COMPLETED BY STUDENT AND REVIEWED BY MEDICAL PROVIDER. Student Name: DOB / / (PLEASE PRINT) Last Name First Name M.I. A) Have you had a previous positive TB Skin Test or positive IGRA Blood Test? No If No Proceed to Part B Yes If yes, circle the test you had (TB Skin Test or IGRA Blood Test) and provide the following: Date Result Date and Result of Chest X-Ray What treatment, if any, was started and when B) 1.Have you ever had close contact with persons known or suspected to have active TB disease? No Yes 2. Were you born in one of the countries listed below that have a high incidence of active TB disease? (If yes, please CIRCLE the country, below) No Yes Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Chad China Colombia Comoros Congo Côte d Ivoire Croatia Democratic People s of Korea Democratic of the Congo Djibouti Dominican Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iraq Japan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People s Democratic Latvia Lesotho Liberia Libyan Arab Jamahiriya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius (Federated States of) Micronesia Mongolia Morocco Mozambique Myanmar Namibia Nepal Nicaragua Niger Nigeria Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar of Korea of Moldova Romania Russian Federation Rwanda Saint Vincent and the Grenadines Sao Tome and Principe Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Sri Lanka Sudan Suriname Swaziland Syrian Arab Tajikistan Thailand The former Yugoslav of Macedonia Timor-Leste Togo Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United of Tanzania Uruguay Uzbekistan Vanuatu Bolivarian of Venezuela Viet Nam Yemen Zambia Zimbabwe 3. Have you had frequent or prolonged visits* (more than 4 weeks) to one or more of the countries listed above with a high prevalence of TB disease? (If yes, CIRCLE the countries, above) No Yes 4. Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease (e.g., hospital, nursing home, or health clinic)? with a high prevalence of TB disease? No Yes 5. Have you been a resident, employee, or volunteer at high-risk congregate settings (e.g., correctional facilities, long-term care facilities and homeless shelters)? No Yes If the answer is YES to any of the above 5 questions, Bucknell University requires that your Health Care Provider complete Part V Page 2 If the answer to all of the above 5 questions is NO and you were not born or traveled to a country listed above, no further testing or action is required and you do not need to have your Health Care Provider complete Part V, Page 2. * The significance of the travel exposure should be discussed with a health care provider and evaluated.

5 PAGE 2 Bucknell Student Health Required Tuberculosis (TB) Screening TO BE COMPLETED ONLY IF STUDENT ANSWERED YES TO ANY OF THE 5 QUESTIONS ON PART V SECTION B Student Name: DOB / / (PLEASE PRINT) Last Name First Name M.I. MEDICAL PRACTITIONER: Screening must be done within 12 months of the first day of classes. A student who has any positive risk factors must be tested for TB infection if there is no written documentation of a previous positive tuberculin skin test (TST) or positive Interferon gamma release assay (IGRA) (e.g. T-Spot, Quantiferon Gold). Previous BCG Immunization does not change TB screening requirements. TB Symptom Check Does the student have signs or symptoms of active pulmonary tuberculosis disease? No Yes Cough (especially if lasting for 3 weeks longer) with or without sputum production Coughing up blood (hemoptysis) Unexplained weight loss Chest pain Loss of appetite Night sweats Fever REQUIRED Tuberculin Skin Test (TST)** ** skintesting.htm Date Given: / / Date Read: / / Result: mm of induration **Interpretation: positive negative OR Interferon Gamma Release Assay (IGRA) Date Obtained: / / (QFT-GIT, T-Spot) Result: negative positive indeterminate borderline (T-Spot only) IF POSITIVE Chest x-ray (Required if TST or IGRA is positive) Date Obtained: / / Result: normal abnormal Provide proof of treatment given for positive TB testing: Medication Date Treatment Started Date Treatment Completed Health care provider (M.D., D.O., P.A., N.P., R.N., school health professional, health official) verifying the above must sign below. Provider Signature Title Date Address Phone Fax