Health Form Requirements

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Health Form Requirements: Please note that the enclosed medical forms must be filled out in English and the immunization records must be translated into English as well. All medical forms MUST be submitted before the student is actually on campus at UMass Dartmouth. Any student who has not turned in their medical forms, translated into English will not be enrolled in classes. You are required to have a physician fill out your immunization records on page 2 and return your completed health forms to Navitas at UMass Dartmouth prior to your arrival. These forms are mandatory and failure to complete them will prevent you from being able to move on-campus and register in classes. Students in the United States are NOT permitted to attend a University without these forms!

Before returning your health forms, please check the following: 

Your immunization history must be completed by a doctor! Immunization records for the following must be accurate, complete, and provided from your doctor or health care facility, page 1 should NOT be completed by the student/parent/agent: 1) M.M.R. – Measles, Mumps & Rubella (2 doses are required at least one month apart). The first dose must be given at least 12 months from date of birth. 2) TDAP – Tetanus, Diphtheria and Pertussis (must be given within the last 5 years) TD only accepted if given within last 2 years. DTP is not acceptable in place of the TDAP vaccine. 3) Hepatitis B Vaccine (3 doses required) *Dose 1 and dose 2 must be at least one month apart *Dose 3 must be four months after dose 1 and at least two months after dose 2 4)

Varicella Vaccine – (2 immunizations required at least 28 days apart) Or positive history of disease (chickenpox) and recorded date

5) Meningococcal Vaccine or signed waiver form

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All pages must be included, including the Meningococcal Waiver if you have not had the vaccine.

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If you have answered Yes to questions 2, 3, or 4 on page 4 of the health forms, it is required that you provide Tuberculin (PPD/ Mantoux) skin test results. The TB skin test must be done within the last 12 months, and results must be read 48-72 hours after the test is applied. If you answer NO to all of the questions on page 4 you are still required to submit complete immunization records!

Please contact us if you have any questions about the health forms or immunization requirements.

Navitas at UMass Dartmouth | 285 Old Westport Road | North Dartmouth, MA 02747 T: +508 990 9661 | F: +508 990 9667 | W: www.umd.navitas.com

UMass Dartmouth Health Services 285 Old Westport Road No. Dartmouth, MA 02747

Office (508) 999-8982 Fax (508) 999-8985

Name:_____________________________________________________________ q Male q Female Date of Birth:___________ q Transgender Permanent Address:___________________________________________________ Student ID#___________________________ _________________________________________________________________ Birthplace (Country): ____________________ Home Phone: (____)_______________Cell Phone: (____)_____________________ Email: _______________________________ Date Entering UMass Dartmouth_______________________________ Entering as: q Undergraduate q Graduate Student Status: q Residential q Commuter If you have been previously enrolled at UMass Dartmouth, please list the date you last attended:_____________________________

PARENT/GUARDIAN/NEXT-OF-KIN INFORMATION (For contact in case of emergency) Name:_____________________________________________________________ Relationship:__________________________ Address:_______________________________________________________________________________________________ Home Phone: (_____)__________________Business Phone: (_____)__________________Fax: (_____)____________________

ALTERNATE EMERGENCY CONTACT: Name:_____________________________________________________________ Relationship:__________________________ Address:_______________________________________________________________________________________________ Home Phone: (____)_______________________________ Business Phone: (____)____________________________________

Only in the event of an emergency would this contact information be released to University Authorities. PRIMARY CARE PROVIDER Name and Phone # :_____________________________________________________ Insurance Coverage – Name of Company: __________________________________________________________________ Address: __________________________________________________________________ Subscriber Name:__________________________________________________ I.D. #________________________________

CONSENT for MEDICAL CARE SIGNATURE OF PARENT/GUARDIAN REQUIRED IF STUDENT IS UNDER 18 YEARS OF AGE, AND IS VALID UNTIL AGE 18. I hereby grant permission to the Director of UMASS Dartmouth Health Services, or authorized representatives to provide such medical care as my daughter/ son ____________________________________ , may require while he/she is a student at UMASS Dartmouth including examinations, treatment, immunizations, etc. This also includes referral to an outside provider, a local hospital, hospitalization, anesthesia and/or surgery should it be necessary in the event of serious illness or injury and I am unable to be reached.

Name of Parent / Guardian (print) __________________________ Signature: _____________________________ Date: __________ 1

UM as s Dar t m out h Requir ed Im m unizat ion and Tuber culos is Scr eening Name ______________________________________________ Student ID #_________________________ Date of Birth__________ Immunization requirements apply to all full time undergraduate and graduate students, all part-time health science students, students here on a visa and all residential students. Both sides of this form must be completed. Signature of healthcare provider is required. Mail or fax to: Student Health Services, UMass Dartmouth, 285 Old Westport Road, North Dartmouth, MA, 02747. Fax (508) 9998985

Required Im m unizations 1. M M R (Measles, Mumps, Rubella)

2 doses required

□ Dose 1 ___/____/____ (received on or after first birthday) □ Dose 2 ___/____/____ (received at least 1 month after dose 1) OR □ Born in USA before 1957. (Except for health science majors) OR □ Positive measles blood titer ____/____/____ (attach lab report) □ Positive mumps blood titer ____/____/____ (attach lab report) □ Positive rubella blood titer ____/____/____ (attach lab report) 2. T da p (Tetanus, Diphtheria, Acellular Pertussis) ___/____/____

3. H e pa titis B immunization 3 doses required □ Dose 1____/____/____ □ Dose 2 ____/____/____ (at least 1 month after dose 1) □ Dose 3 ____/____/____(at least 2 months after #2 and 4 months after #1) OR □ Recombivax 10 mcg given ages 11-15 (2 doses at least 4 months apart) Dose 1 ____/____/____ Dose 2 ____/____/____ OR □ Positive Hepatitis B serology(HBsAb) ____/____/____ (attach lab report)

( Record using Month/Day/Year format) mm/dd/yyyy

4. Va rice lla (Chicken Pox) 2 doses required □ Dose 1____/____/____ □ Dose 2 ____/____/___ (at least 1 month after #1) OR □ Born in USA before 1980 (Except for health science majors) OR □ Positive Varicella titer ____/____/____ (attach lab report) OR □ History of the disease verified by healthcare provider ____/____/____ (Date of disease) 5. M e ningitis Va V a ccine (required for resident students only). ____/____/____ OR □ Not a residential student and is exempt from meningitis requirement OR □ Signed waiver (attach waiver ) 6. D a te of la s t T D ____/____/____

Tuberculos is Tes ting For H igh Ris k Only

( TB testing is required only if you answered yes to questions 2, 3 or 4 on page 4.) □ TB skin test (Mantoux, PPD) Date given: ___/___/___ Date Read: ___/___/___ Result: ______mm of induration * Interpretation ____ Negative ____Positive. *(See table below for interpretation of result) OR □ IGRA blood test (Quanterifon) ____/____/____ Negative _____ Positive (attach lab report) Result: ____ Ris k Fa ctor P os itive Re s ult Close contact with a case of tuberculosis 5 mm or more Born in a country that has a high rate of tuberculosis 10 mm or more. Traveled or lived for a month or more in a country that has 10 mm or more a high rate of tuberculosis No risk factors (test not recommended) 15 mm or more If tube rculos is te s ting is pos itive , now or by history, the following are re quire d 1. Date of positive test___/____/____ 2. Chest X-ray required. ____/____/____ (Attach report ) 3. Clinical Evaluation Normal Abnormal (describe) _____________________________________________________________________ 4 Treatment No Yes (drug, dose, frequency and dates_________________________________________________________________

H ealthcare Provider Signature (Required unless you attached a copy of an immunization record.) _________________________________________ Name

____/____/____ Date

_____________ Phone

__________ Fax

2

Name:

Student ID# MEDICAL HISTORY

FAMILY HISTORY Age State of Health

Age of Death

Cause of Death

Have any of your immediate relatives had any of the following: Yes Relationship



Father Alcohol/ Substance Abuse Mother Cancer Brothers Diabetes Heart Disease Sisters High Blood Pressure Kidney Disease Spouse Neuromuscular disorder Children Mental Illness Tuberculosis PERSONAL HISTORY (Do you have now or have you ever had: (Check all that apply) q Anemia q Anorexia Nervosa/Bulimia q Appendectomy q Arthritis q Asthma q Blind/visual impairment q Cancer/malignancy q Chickenpox q Crohn’s/Ulcerative Colitis q Deaf/hearing impairment

q Depression q Diabetes q Drug/Alcohol problems q Emotional/mental illness q Heart disease/problem q Hepatitis (Type________) q High blood pressure q High cholesterol q Impaired mobility/paralysis q Irritable Bowel Syndrome

q Kidney disease/ stones q Learning disability q Loss of paired organ (eye, kidney) q Malaria q Migraines/chronic headaches q Mononucleosis q Neuromuscular disease q Phlebitis/deep vein clot q Pneumothorax q Seizure disorder

q Sickle cell disease q Sleep problems q Thyroid disease q Positive TB test q Tuberculosis disease q Ulcer/stomach problems q Urinary Tract Infection (frequent/recurrent) q Oth-

PLEASE EXPLAIN ALL POSITIVE ANSWERS (with dates): ________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ INPATIENT HOSPITALIZATIONS: Please list all medical/psychiatric hospitalizations, dates, and diagnoses: __________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ MEDICATIONS: Please list all (prescription and over-the-counter) including birth control, asthma medications, antidepressants, herbal supplements, etc: _______ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ALLERGIES: q None Known q Yes (If yes, please specify, including medications, insect venoms, foods, etc.)____________________ _________________________________________________________Type of reaction:_____________________________________ 1. Do you smoke cigarettes? q Yes q No Number per day? ______________ For how many years? __________________________________ 2. Do you drink alcohol? q Yes q No How often? _____________ When you drink, how many do you usually have? _____________________ 3. Do you now or have you ever used recreational drugs? q Yes q No Which ones? ______________________ How often? _______________ 4. Do you follow any diets? q Yes q No What Kind? ______________________ Are you concerned about your eating habits? q Yes q No 5. How much do you weigh? ____________ How Tall are you? ______________ What is your desired weight? _____________________ lbs. 6. Do you often have a feeling of being anxious, overwhelmed or depressed? q Yes q No 7. Have you ever received treatment or counseling for an emotional problem? q Yes q No 8. Are you currently in counseling/therapy? q Yes q No Dates of treatment: _____________________________________________________

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Name:

Student ID#

Date of Birth

Medical Evaluation for Latent Tuberculosis Infections All students must answer the following questions: 1. Have you ever had a positive tuberculosis skin test? q Yes q No (If yes, have your health care provider fill out Page 1.) 2. To the best of your knowledge, have you had close contact with anyone who was sick with tuberculosis (TB)? q Yes q No 3. Were you born in one of the countries listed below? q Yes q No 4. Have you traveled or lived for more than one month in any of the countries listed below? q Yes q No

COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB) Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad China Colombia Comoros Congo

YES

NO

Cote d’lvoire Croatia Democratic People’s Republic of Korea Democratic Republic of the Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Figi Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iraq Japan

Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Lao PDR Latvia Lesotho Liberia Libyan Arab Jamahiriya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia (Federal States of) Mongolia Morocco Mozambique Myanmar Namibia Nauru Nepal New Caledonia

Nicaragua Niger Nigeria Northern Mariana Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Vincent and the Grenadines Sao Tome & Principe Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Sri Lanka

Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Maccdonia Timor-Leste Togo Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvula Uganda Ukraine United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Wallis and Fortuna Yemen Zambia Zimbabwe

TO QUESTIONS 2, 3, OR 4 – Requires that you have tuberculosis testing, either by skin testing or a blood test to check for latent tuberculosis infection.

TO ALL OF THE ABOVE QUESTIONS – Means that you are considered low risk for tuberculosis,

and that a tuberculosis test should not be done

Office (508) 999-8982 Fax (508) 999-8985

HIGH RISK

LOW RISK

UMass Dartmouth Health Services 285 Old Westport Road No. Dartmouth, MA 02747 4