Preparing for your Pathways Program
SPRING 2016
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Navitas at UMass Lowell
Table of Contents: Letter from Staff…………………………………………………………………………………………. 3 About Lowell/UMass Lowell……………………………………………………………………….…..4 On-campus Accommodations……………………………………………………………………….…5 Orientation Information………………………………………………………………………………...7 Immigration Information…………………………………………………………………………….…8 Traveling to the United States………………………………………………………………………..9 Adjusting to Life at UMass Lowell…………………………………..……………………………..10 Monetary Information………………………………………………………………………………….11 Packing List………………………………………………………………………………………………..12 Frequently Asked Questions…………………………………………………………………………14 Airport Pick up form……..………………………………………………………………………….…15 Student Accommodation at UMass Lowell………………………………………………………16 Spring Housing Registration…………………………………………….…………….……….……20 Checklist………………………………………………………………………………………………….…21 Health forms………………………………………………………………………………………………23
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Navitas at UMass Lowell
Dear Incoming Navitas Student, Congratulations on your admission to Navitas at UMass Lowell. You have chosen to attend a premiere university in the United States which is nationally recognized for its research and academic programs. I am sure that you will be delighted with your decision to earn your degree here. At Navitas at UMass Lowell, you will be taught by some of the best professors in the United States. You will be located on a dynamic campus along the Merrimack River, with access to all the recreation and social opportunities available on campus, throughout the historic city of Lowell, and across New England. The caring staff at Navitas at UMass Lowell is aware of the mixed feelings of excitement and anxiety that you must be experiencing now, and will experience as you settle in here. We will provide you with a warm welcome and will continue to support you in your adjustment to life at an American University and in magnificent Lowell. Please stay in touch with us over the next few weeks. We will be sending you information to make your arrival and stay as easy and pleasurable as possible. Please do not hesitate to ask us any questions that you might have. When you get your visa, feel free to make your travel arrangements. If you require airport pick up, please contact our admissions office with the details so that we can arrange for someone to meet you and bring you to campus. Once again, congratulations and welcome to the community. We are so pleased that you are joining us here at UMass Lowell and really look forward to meeting you soon. Sincerely, Navitas Staff
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Navitas at UMass Lowell
Studying and learning with Navitas at UMass Lowell At Navitas at UMass Lowell we understand that the transition to university-level study can be difficult. To assist you in developing the study skills necessary to successfully complete your program, we offer a variety of support services. In your Pathways Program, you will take a full-time schedule, typically five courses per semester and any required laboratories. All professors have office hours where they can meet with you and address any concerns you have about your progress in the course. The small class sizes and specialized instruction will help you improve your skills. Meetings with academic advisors will happen throughout the semester, as well. Student involvement UMass Lowell has over 100 clubs and organizations. Groups such as the Biology Club, Math Club, Society of Environmental Scientists, Indian Student Association, Association of Students of African Origin, International Student Organization, Cambodian American Student Association, Christian Student Fellowship, Latin American Student Association, Middle Eastern Student Association, Vietnamese Student Association, and French Club, to name a few. Or join their Ballroom Dancing Club and partake in their annual Dancing with the UML Stars competition. Starting an undergraduate or graduate club is an easy process. If there is currently no club or organization that matches your interest, you may consider organizing a new one. All about the city of Lowell State: Massachusetts Population: 105,167 Area: 14.5 square miles (37.6 square kilometers) Currency: United States Dollar Time Zone: Eastern Standard Time Electricity: 120V Languages: English Religions: Over 40 religious groups including Catholic, Protestant (Baptist, Methodist, Episcopal), Muslim, Jewish, Buddhist, Hindu, Greek Orthodox, and more. Climate: Lowell has a wonderfully diverse climate with warm summers, cold winters and a mild spring and fall. The unpredictable weather which can change very quickly is often a topic of polite conversation. The average low temperature is around 24°F (-4°C) and highest is around 85°F (29°C) over the year.
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Navitas at UMass Lowell
Things to do Boating, hiking, skiing, ice hockey, golf, soccer, biking, white water rafting, whale watching, live music concerts, Lowell Spinners Baseball games, art galleries, and eight free festivals a year. Attractions in the surrounding area Boston’s historic Freedom Trail, Fenway Park (home to the Boston Red Sox), the White Mountains, beaches, ski resorts, and Cape Cod. On-campus accommodations UMass Lowell guarantees you on-campus housing as a Navitas at UMass Lowell Pathways student. As a Pathways student, your housing is coordinated for you. Please do not book any accommodation on your own. All undergraduate students are required to stay on campus during their first year. In addition to achieving a higher degree of academic success, students who live on campus tend to have a greater connection to the university, are more involved with the community, and take greater advantage of the services and extra-curricular activities available. There are also the special friendships and bonds you will make by living in on-campus housing. Residences All of the residence halls offer amenities and features that will help you stay focused on academics. The residence halls are only a short walk from the classroom buildings, dining halls, Tsongas Center, LeLacheur Baseball Park, Campus Recreation Center, the University Library, and more. Each room includes a bed, dresser, desk, chair, and wardrobe. Rooms are wired for high-speed Internet access, standard cable television, and for local and on campus calling; however, you must purchase your own phone and television. Many of the residence halls have common TV rooms, common laundry facilities and vending machine areas. Fox Hall has common kitchens that you may use if you would like to prepare your own meals. Academic facilities Students who live on campus have the opportunity to spend more time in the academic rooms, computer rooms, libraries and the Centers for Learning and Academic Support Services (CLASS). Campus dining Campus dining at UMass Lowell is varied and distinctive. There are eight locations to choose from, including 3 dining halls and 2 restaurants, which offer everything from made to order dinners, salad bars, grills, deli, and fast food options. The meal plan covers meals each day for the entire week of the semester. Between semesters, special arrangements are made.
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Navitas at UMass Lowell
Students under the age of 18 Enrolled students under the age of 18 are allowed to live on campus. All students under the age of 18 must have a parent or legal guardian sign the housing contract as well as the health form allowing medical treatment for students. Shuttle bus The university shuttle bus transports students around campus seven days a week. Any activity the university offers is only a quick shuttle trip away. Most buildings can be accessed on foot. Airport pickup We provide transportation from Boston Logan International Airport to UMass Lowell residence halls. To request pick up upon arrival to Boston Logan International Airport, please fill out the form online through the link given at the back of this packet. Send it to
[email protected] at least one week before arrival.
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Navitas at UMass Lowell
Orientation and Arrival to the United States Before the start of the semester, Navitas and UMass Lowell offers an orientation program to help you prepare for the semester. At orientation you will learn all you need to know about life at UMass Lowell. You will tour the campus, meet the staff of the International Students and Scholars office, set up a US bank account and prepare to start the semester. Move-in and Check-in day: January 13th, 2016 Orientation: January 14th, 2016 If the weather conditions are severe, the University will be closed. In this case, the Check-in day will be moved to the following day. Please make sure to arrange accommodation for the night appropriately. If you would like to arrive in Lowell prior to the start of orientation, you will need to make arrangements for where to stay prior to moving into residence. The Inn and Conference Center at UMass Lowell offers special discounts for UMass Lowell international students. In order to make a reservation, please visit https://booking.ihotelier.com/istay/istay.jsp?HotelID=73933. You will need to pay for your stay by credit card upon arrival. The Radisson Hotel & Suites Chelmsford-Lowell is a short distance from campus offering free shuttle service to UMass Lowell. In order to make a reservation, please visit http://www.radisson.com/chelmsford-hotel-ma-01824/chelmsfo. You will need to pay for your stay by credit card upon arrival. If you plan on traveling within the United States before the start of classes, plan on arriving to the US early and arriving in Lowell on time for orientation.
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Navitas at UMass Lowell
Applying for your F-1 Student Visa It is necessary for non-US citizens to have visas to enter the United States. To study in your Navitas at UMass Lowell program, you will need to apply for an F-1 visa. Visa applications are made at US consulates or consular sections of US embassies closest to an individual's place of residence. To apply for a visa you must have
A valid passport OR acceptable travel document Proof that you are the person identified by the passport Required photographs (please follow the embassy or consulates guidelines for these photos) Funds for any required fees Proof of prior education (transcript, diploma, etc.) A form I-20 (for F-1 visa) or DS-2019 (for J-1 visa) issued by UMass Lowell Proof of admission to that institution (letter of acceptance) Proof that you have sufficient funds to study (bank statements or bank letter)
You should be prepared to demonstrate that you have close ties to your home country and, as you are applying for a non-immigrant visa, that you have full intention of returning home after you complete your studies.
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Traveling to the United States Legal Documents to have in your possession: You may be asked to present all the following at the Port of Entry, so have them easily accessible in your carry-on along with your airline tickets:
Passport Visa Document (Form I-20) - If the US Embassy returned your visa document in a sealed envelope only to be opened by a US Official at the U.S. Port of Entry, please honor this. UMass Lowell Admissions letter The Original Financial Documentation that you provided to US Embassy or Consulate
At the Port of Entry, the officer will return the Form I-20 back to you. The Official at the Port of Entry will write “F-1” and “D/S” according to your visa type. Make sure they do this correctly before walking away. If they do not, politely ask them to do so. Also refer to the Port of Entry information sent to you by the UMass Lowell International Students and Scholars Office (ISSO). Sometimes Customs and Border Protection agents may not appear friendly. Do not be nervous, calmly present the documents that the agents request and answer any questions they ask you.
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Navitas at UMass Lowell
Adjusting to Life at UMass Lowell Cultural adjustment When you start your pathways program at UMass Lowell, it will be necessary to make a cultural adjustment. It is normal to miss your friends, your family and your home. The UMass Lowell community will be here to help you adjust. Here are some ways you can help yourself adjust to studying here.
Be aware that you may experience some sadness or home sickness.
Have a tolerance for ambiguity and for differences. Remain open minded, flexible and adaptable. Try to suspend judgment until you have looked for the logical reasons behind differences. Be objective and perceptive.
Stay busy. Get involved with activities on the UMass Lowell campus. You may find that you can continue with the same sports or hobbies you did in your home country.
Find an American to be a “cultural informant” who will help you gain proper perspective. Be curious and ask questions about your new surroundings and American customs. People will enjoy responding to your interest in understanding American culture.
Focus on the positive things about UMass Lowell and living in the US.
Keep your self-confidence. Believe you can do it and keep in mind the many strengths and advantages you will have when you succeed in your studies in the United States.
Living with a roommate If you have never lived with a roommate before, there will be an adjustment period after you first move in. Don’t worry, many American students have never lived with a roommate before either, and living with a roommate can be a lot of fun. Here are some hints to living with a roommate:
Be friendly - If you are nice and friendly to your roommate, it is likely to be reciprocated. Be understanding - Try to see the motives behind your roommate’s actions and help if you can.
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Navitas at UMass Lowell
Give your roommate some peace and quiet sometimes - It’s great to have conversation, however, everyone needs time to be alone and of course, to study. Do not use your roommate’s belongings - If there is something that you would like to use, ask! Keep it clean - Help keep the room clean. No one wants to live in filth. Talk it out - If you are having a problem with your roommate, talk to them. A good relationship with your roommate will require some give and take. Treat you roommate as you wish to be treated - It is as easy as that.
How much money to bring We recommend that you not carry more than $1000 in cash (the cash should include small bills.) You may want to keep the cash in two separate areas easily accessible to you. Be aware of your personal belongings at all times during your travel. It is unsafe to carry a lot of cash, so please try not to carry more than $1000. We will help you arrange a bank account in Lowell in your first week so that money can be wired or deposited. Your on-campus meal plan provides 19 meals per week during the regular semester. If you choose to eat off campus, meals generally cost $5-10 for breakfast, $5-15 for lunch, and $10-40 for dinner. During certain US holiday periods, on-campus food choices will be limited.
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What to Pack and What to Purchase Upon Your Arrival Navitas and UMass Lowell will organize a shopping trip after you arrive on campus. You will have the opportunity to visit many different stores. See the list below of what you can purchase upon your arrival. What to bring with you: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
12. 13.
14.
3-10 light shirts or T-shirts 2-4 pairs of pants (either light fabric or 2-3 pairs of jeans) 2-4 pairs of shorts (you may need them in the summer time) 1 jacket or coat (you will need it in the winter time) 5-10 long sleeve shirts or sweaters 1-2 formal outfits (men should bring 1 dress blazer and 1 tie, which could be purchased here). You may want to bring a traditional formal outfit from your country for special cultural events. Shoes can be bought in the US at reasonable prices, but it will be helpful to bring a pair of sneakers or comfortable shoes, sandals, etc. as well as one dress pair of shoes. 7-10 pairs of undergarments 1-2 pairs of pajamas Toiletries - toothbrush, toothpaste, soap, hair brush, deodorant, shampoo, shaving supplies, feminine protection, etc. Medication - You will need to carry a doctor’s note for any prescription medication as you’ll need to present this at airport(s). Follow the immunization instructional information which was provided to you from the UMass Lowell Health Services Department. Here is their contact information in case you have any last minute questions, http://www.uml.edu/student-services/Health/Contact-Us.aspx Your favorite music or books Software, computer, educational material- a scientific calculator, a school bag or backpack. Computers are reasonably priced in the US if you prefer to purchase one upon your arrival. Follow this link to learn more about the recommended hardware configuration and software to you will need at UMass Lowell. There are computer labs on campus that run Microsoft Office 2007 that you will be able to use, http://www.uml.edu/IT/Services/Hardware/Student-HardwareRecommendations-Software-Licenses.aspx Electrical Equipment- outlets in the US operate with a voltage of 110-120 volts, 60 cycles. If your equipment requires 220 volts, bring a converter and plug adapter. If it operates within 110 and 240 volts, bring a plug adaptor.
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Navitas at UMass Lowell
Things you can purchase when you arrive: 1. 2. 3. 4. 5. 6. 7. 8. 9.
A warm coat for winter Any additional clothing Winter shoes and boots Bedding (extra-long twin sheets, blankets, pillows) Additional toiletries Food Supplies to wash clothes School supplies (pens, pencils, etc.) SIM card and cell phone
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Navitas at UMass Lowell
Frequently Asked Questions: Q: When should I come to the United States? A: You may enter the US up to thirty days prior to the start date found in “section 5” of your Form I-20, as long as you have a valid F-1 visa. You should make sure you are in Lowell, Massachusetts by the start date of orientation. Remember, you will not be able to move into residence until January 13th, 2016. Q: Is the water safe to drink? A: Yes, almost everywhere in the United States there is safe drinking water. There are water fountains all over campus for you to take a drink or fill up a water bottle.
Q: What banking options will I have in Lowell? A: There are a number of banks to choose from in Lowell, however, most students use Bank of America because of their on-campus ATM locations. During orientation you can meet with a Bank of America representative to learn about the banking options and sign up for an account.
Q: What will I need to do when I arrive? A: You must attend orientation starting on January 14th, so you may choose to rest up between the time you arrive and the start of the orientation program.
Q: What can I do if I become homesick? A: During orientation you will learn about homesickness and how to deal with it while you study at UMass Lowell. You will also hear about the free counseling services available to students of UMass Lowell.
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Navitas at UMass Lowell
Request for Airport Pick-up
Whether you request an airport pick up or not, please proceed to the link below and fill out the required arrival confirmation form: http://www.uml.navitas.com/arrival-booking Airport pick up is available for students that land at Boston Logan International Airport between the hours of 7:00am and 7:00pm. If you arrive outside of those times, you must arrange your own transportation to campus. If you have any problems or concerns, please feel free to contact our Student Administrative Support Officer, Christopher Acha,
[email protected]
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Navitas at UMass Lowell
Student Accommodation at UMass Lowell Living in the residence halls can have a positive impact on your entire university experience at UMass Lowell. Research shows that students who live on campus earn higher marks in their academics than those who do not. Students also feel more connected to the university community. We are dedicated to ensuring that all students succeed in their pathways program and move on successfully to the University. As you begin the process of signing up for housing, we want to provide you information and suggestions on how we can be most helpful in this process. Please be aware of some basic information about the housing process:
All First Year UPP (pathways) undergraduate students are required to live on campus for their first year. First-year students live in residence halls, predominately in double or triple occupancy rooms -based on availability- in traditional halls (Please see next page for a description). Typically, first year students are housed together in the same area; the skills and lifetime friendships you make will ease your transition into the University community. The student housing application is included in your packet. All incoming students must fill out and submit their application. Please do NOT submit a housing deposit, this fee is waived from the application process. Student Housing is guaranteed for all students that submit their Housing forms by the January 2nd deadline. Housing assignments will be provided upon check-in on January 13th, 2016.
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Navitas at UMass Lowell
How to manage your assignment expectations:
The first year of university in a new country can be an overwhelming and challenging experience. The University does its best to make sure your academic experience is desirable and comfortable. Please understand the Office of Residence Life does it’s best to accommodate all requests made by students. Once on campus, you will have the opportunity to request a room change.
Room changes: On-campus room assignments are for the entire academic year. The office of Residence Life will consider requests for room changes by a student after they have been in residence for two weeks. Changes prior to that time will be considered only for emergency/health cases. Meal plans:
All students living in traditional style residence halls are required to be on a residential meal plan. You will be enrolled in the Platinum meal plan which comes with Riverhawk cash to spend across campus. For more information on dining services and meal plan options please visit, http://umasslowell.campusdish.com/Commerce/Catalog/ShopSubCategory.a spx?category=Student_Not_Required_to_Buy_6917&lid=6917&root=Meal_Pl an
Questions? If you have any questions please don’t hesitate to contact me. Please call 978-9341902 or email Kyle Lapham at
[email protected]. We believe that your living experience should be exciting, and we look forward to working with you to make it as such. Good luck with your preparations to attend the University of Massachusetts Lowell’s Pathways Program! We look forward to greeting you. Sincerely, Kyle Lapham Student Services Officer
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Navitas at UMass Lowell
Brief Information: Residence Halls and Apartments Each residence hall offers a variety of room options and benefits: East Campus Bourgeois Hall doubles, triples, and quads easy access to the parking garage and bus stop Donahue Hall four-person, six-person, and eight-person suites each suite has its own bathroom and common area Fox Hall doubles, triples, and quads boasts the largest dining hall on campus Leitch Hall singles (by medical request only), doubles, triples, and quads First semester students only; easy access to Campus Recreation Center University Suites Four-person and six-person suites steps from the Campus Rec Center Downtown Lowell The Inn and Conference Center at UMass Lowell doubles and triples private bathrooms and individual climate controls South Campus Concordia Hall singles and doubles great open common area on the first floor Riverview Suites four-person and six-person apartments full kitchens, living rooms and bathrooms within each unit
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Navitas at UMass Lowell
Sheehy Hall four-person, six-person, and eight-person suites convenient for anyone in a South Campus major For videos and more information on Residence Halls and Campus Apartments please visit, www.uml.edu/reslife
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How to Register for Spring Housing
All the First Year UPP undergraduate pathways students are required to live on campus for their first year. Please be aware that now you have to register for Housing directly by submitting a Housing Contract online. You must complete this by January 2nd! Please click on the link below and follow further instructions: Click here for UMass Lowell Spring Housing Link
We do our best to meet your accommodation requirements, however, university housing often has a limited number of rooms with select preferences, which are given to students on a first come, first served basis. This means that your preferences are not guaranteed. Please make sure to read the housing policy handbook prior to your arrival on campus. When you arrive, you will be expected to complete a form that states that you have read the handbook and understand the policies. The link to the handbook is provided below: http://www.uml.edu/docs/ORL%20Guidelines%202014-2015%20updated%209-214_tcm18-152655.pdf If you have any problems or concerns please feel free to contact our Student Services Officer, Kyle Lapham,
[email protected]
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Navitas at UMass Lowell Are you ready?
Checklist: What you must do before arrival Pay SEVIS fee and make appointment with the US Embassy or Consulate Instructions from the ISSO is included in this packet. Go to the US Embassy or Consulate and obtain your F-1 visa. Please notify Navitas as soon as you’ve received your visa. Initial invoice for UPP Program Payment of your initial invoice is due within 14 days of receiving your F-1 visa, or by December 30th, whichever is earlier. Please note that you will not be enrolled in classes until your invoice has been paid in full. Payment by December 30th will prevent delays in your registration. Navitas Spring Housing Contract – return January 2nd Please submit your Housing Contract through the link provided on page 20 by January 2nd. We cannot secure campus accommodation at UMass Lowell for you without this form. Please note that all undergraduate pathways students are required to live on campus during the first year while enrolled in the university pathways program. Please refer to Housing information sheet in this Packet to see more information about housing options. Please see the invoice included in this packet. UMass Lowell Health Forms Please submit your completed health forms, with all required immunizations, to the Health Service Center (220 Pawtucket St., University Crossing, Suite 300, Lowell, MA 01854) by the first day of orientation, which is on Thursday January 14th. Students in the United States are not allowed to live on campus or attend classes without these immunizations, so it is important that these are sent to us prior to your arrival on campus. If you have questions about the required immunizations, please feel free to contact the Health Services Center,
[email protected]. Arrival Forms/ Airport Pickup Request – return by January 6th As soon as you have booked your flights, please email us your Arrival Form with your travel plans. It is important that you confirm your travel plans as soon as possible, so that we can plan for your arrival to campus. If you require an Airport Pickup from Boston Logan International Airport, you must also return the enclosed Airport Pickup Request by January 6th with your full flight itinerary. In order to reserve Airport Pickup, please see, http://www.uml.navitas.com/arrival-booking. Airport pick-up is $125 USD.
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What You Must Do Upon Arrival International Orientation is January 14th-15th, 2016 Please make travel arrangements to arrive at Boston Logan International Airport no later than January 13th, 2015. Orientation, which is mandatory for all new students, begins on Thursday January 14th so you should plan to arrive in Lowell, Massachusetts before this date. The campus residence halls will be open for move-in between 9:00am-9:00pm on January 13th. Please note that if you arrive before January 13th, you will need to make arrangements for a place to stay until the residence halls are open. In case of arrival at the University after 9:00pm, you are responsible for your own overnight accommodation. Check in with the International Students and Scholars office (ISSO) Each semester, the ISSO requires each international student to register in the SEVIS system, verifying enrollment as a full-time student and confirmation of US address. Failure to do this automatically cancels the student’s immigration status. All Navitas students must register with the ISSO during orientation. Required documents for check-in include
Passport Form I-20 Visa Copies of I-94
I-94 information is available through www.cbp.gov/I94.
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Health Forms Letter Please note that our process of receiving your health forms has changed. Please do not send health forms directly to Navitas at UMass Lowell. All students are required to fill out health forms. Health forms can be mailed to the address below or students can bring forms to Orientation. UMass Lowell Student Health Services University Crossing Suite 300 220 Pawtucket Street Lowell, MA 01854 As authorized under the insurance laws for higher education, students in Massachusetts (section 275 of Chapter 151 of the Acts of 1996), the University of Massachusetts Lowell requires that all international students must enroll in the University’s Student Health Insurance Plan. Thank you for your cooperation. We look forward to welcoming you the University. Sincerely, Kyle Lapham Student Services Officer Navitas at UMass Lowell
University of Massachusetts Lowell Health Services – Wellness Center 220 Pawtucket St., Suite 300 Lowell, Ma 01854-5144 Tel: 978-934-4991 Fax: 978-934-3080
CONSENT FOR TREATMENT for under 18 Students
I hereby give permission for medical treatment for my dependent , _____________________________, if an accident or illness should occur while he/she is a student at the University of Massachusetts Lowell. This includes referral to a local hospital or hospitalization, should it be necessary and I am unable to be reached. This permission shall be granted for the period of one academic semester and must be renewed every semester that my child is a student at the University of Massachusetts Lowell.
________________________________________ Child’s full name (please print)
______________ (date of birth)
________________________________________ Parent/Guardian name (please print)
______________ Date
Parent/Guardian Signature: ________________________________________
Navitas Student
HEALTH SERVICES University of Massachusetts Lowell Wellness Center 220 Pawtucket Street, Suite 300 Lowell, MA 01854-5144 Tel: (978) 934-6800 Fax: (978) 934-3080
Name: Date:
Last
/
TUBERCULOSIS RISK ASSESSMENT (Page 1 of 2)
First
/
DOB:
/
/
Male
M.I.
SID#:
Country
of
Female
Birth:
Home Address: Local Address: Phone Number: (home)
(cell)
Please answer the following questions: 1. Have you ever been in a close contact with anyone sick with tuberculosis?
Yes
No
2. Were you born in one of the countries listed below? If yes, what country:
Yes
No
Yes
No
Date of entry to United States:
3. Have you lived or traveled for more than one month in one or more of the countries listed below? If yes, what country/ies: When:
If the answer is NO to all of the above questions, no further testing is required. Submit form to Health Services If the answer is YES to any of the above questions, UMASS Lowell Health Services requires you to have a tuberculosis skin test (TST) to check for latent tuberculosis infection (LTBI). TST must be completed no more than 6 months before the start of classes. TST preferred to be completed in USA. Continue to Page 2 of this form.
*COUNTRIES WITH HIGH RATES OF TUBERCULOSIS Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde
Central African Republic Chad China Colombia Comoros Congo Congo DR Cote d’Ivoire Croatia Djibouti Dominican Republic Ecuador El Salvador Equatorial New Guinea Eritrea Estonia Ethiopia Fiji Gabon Gambia Georgia Ghana Guam
Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iraq Japan Kazakhstan Kenya Kiribati Korea-DPR Korea-Rep Kuwait Kyrgyzstan Lao PDR Latvia Lesotho Liberia Libyan Arab Jama Lithuania
Macedonia-TFYR Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia Moldova-Rep Mongolia Morocco Mozambique Myanmar Namibia Nepal New Caledonia Nicaraqua Niger Nigeria Northern Mariana Island Pakistan
Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwuanda St. Vincent & Grenadines Sao Tome & Principe Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Sri Lanka Sudan
Suriname Syrian Arab Republic Swaziland Tajikistan Tanzania-UR Thailand Timor-Leste Togo Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe
*World Health Organization Global Tuberculosis Control. WHO Report 2010. www.who.int/globalatlas/dataQuery/default.asp Rev: 15/05
HEALTH SERVICES University of Massachusetts Lowell Wellness Center 220 Pawtucket Street, Suite 300 Lowell, MA 01854-5144 Tel: (978) 934-6800 Fax: (978) 934-3080
Name: Date:
Last
/
/
TUBERCULOSIS RISK ASSESSMENT (Page 2 of 2)
First
DOB:
/
/
Middle Initial
SID#:
Country of Birth:
Home Address: Local Address: Phone Number: (home)
(cell)
Tuberculin Skin Test (TST) Plant date:
/
/
Read date*:
*48-72 hours after plant date
/
/
mm of induration
Result**:
^Positive Negative
**If no induration, write “0". See interpretation guidelines below. ^If positive, continue below.
If POSITIVE Tuberculin Skin Test (now or by history) the following are required: /
Date of Positive TST: Chest X-ray:
/
Normal
Abnormal (attach report, NOT the X-ray) Normal
Clinical Evaluation:
mm of induration
Result:
Date:
/
/
Abnormal
Describe: Treatment:
No
Yes
Drug/s, dose frequency, and dates:
Medical Provider Name:
Address:
Signature:
Phone:
**Interpretation Guidelines 5 mm or greater is positive:
10 mm or greater is positive:
• Recent close contacts of an individual with infectious TB • Persons with fibrotic changes on a prior chest x-ray consistent with past TB disease • Organ transplant recipients • Immunosuppressed persons: taking > 15 mg/d; of prednisone for > 1 month; taking a TNF-a antagonist • Persons with HIV/AIDS
• Persons born in a high prevalence country or who resided in one for a significant amount of time • History of illicit drug use • Mycobacteriology laboratory personnel • History of resident, worker or volunteer in high-risk congregate settings • Persons with the following clinical conditions: silicosis, diabetes mellitus, chronic renal failure, leukemias and lymphomas, head, neck or lung cancer, low body weight (>10% below ideal), gastrectomy or intestinal bypass, chronic malabsorption syndromes
15 mm or greater is positive: • Persons with no known risk factors for TB disease
Rev: 15/05
Information about Meningococcal Disease and Vaccination and Waiver for Students at Residential Schools and Colleges Massachusetts requires all newly enrolled full-time students attending a secondary school (e.g., boarding schools) or postsecondary institution (e.g., colleges) who will be living in a dormitory or other congregate housing licensed or approved by the secondary school or institution to: 1. receive meningococcal vaccine; or 2. fall within one of the exemptions in the law, which are discussed on the reverse side of this sheet. The law provides an exemption for students signing a waiver that reviews the dangers of meningococcal disease and indicates that the vaccination has been declined. To qualify for this exemption, you are required to review the information below and sign the waiver at the end of this document. Please note, if a student is under 18 years of age, a parent or legal guardian must be given a copy of this document and must sign the waiver. What is meningococcal disease? Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can infect the tissue that surrounds the brain and spinal cord called the “meninges” and cause meningitis, or they can infect the blood or other body organs. In the US, about 1,000-3,000 people get meningococcal disease each year and 10-15% die despite receiving antibiotic treatment. Of those who live, another 11-19% lose their arms or legs, become deaf, have problems with their nervous systems, become mentally retarded, or suffer seizures or strokes. How is meningococcal disease spread? These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an infected person’s saliva in order for the bacteria to spread. Close contact includes activities such as kissing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is infected; or being within 3-6 feet of someone who is infected and is coughing or sneezing. Who is at most risk for getting meningococcal disease? High-risk groups include anyone with a damaged spleen or whose spleen has been removed, those with persistent complement component deficiency (an inherited immune disorder), HIV infection, those traveling to countries where meningococcal disease is very common, microbiologists and people who may have been exposed to meningococcal disease during an outbreak. People who live in certain settings such as college freshmen living in dormitories and military recruits are also at greater risk of disease. Are some students in college and secondary schools at risk for meningococcal disease? College freshmen living in residence halls or dormitories are at an increased risk for meningococcal disease as compared to individuals of the same age not attending college. The setting, combined with risk behaviors (such as alcohol consumption, exposure to cigarette smoke, sharing food or beverages, and activities involving the exchange of saliva), may be what puts college students at a greater risk for infection. There is insufficient information about whether new students in other congregate living situations (e.g., residential schools) may also be at increased risk for meningococcal disease. But, the similarity in their environments and some behaviors may increase their risk. The risk of meningococcal disease for other college students, in particular older students and students who do not live in congregate housing, is not increased. However, meningococcal vaccine is a safe and efficacious way to reduce their risk of contracting this disease. Is there a vaccine against meningococcal disease? Yes, there are currently 2 types of vaccines available that protect against 4 of the most common of the 13 serogroups (subgroups) of N. meningitidis that cause serious disease. Meningococcal polysaccharide vaccine is approved for use in those 2 years of age and older. There are 2 licensed meningococcal conjugate vaccines. Menactra® is approved for use in those 9 months – 55 years of age and Menveo® is approved for use in those 2-55 years of age. Both the polysaccharide and conjugate vaccines provide protection against four serogroups of the bacteria, called groups A, C, Y and W-135. These four serogroups account for approximately two-thirds of the cases that occur in the U.S. each year. Most of the remaining one-third of the cases are caused by serogroup B, which is not contained in either vaccine. Meningococcal vaccines are thought to provide protection for approximately 5 years. Currently, students are only required to have a dose of polysaccharide vaccine within the last 5 years or a dose of conjugate vaccine at any time in the past (or fall within one of the exemptions allowed by law). (See reverse side)
However, please be aware that in October 2010 the Advisory Committee on Immunization Practices (ACIP) recommended booster doses of meningococcal conjugate vaccine for healthy adolescents 16-18 years of age. Persons up to 21 years of age entering college are recommended to have documentation of a dose of meningococcal conjugate vaccine no more than 5 years before enrollment, particularly if they are new residential students. Is the meningococcal vaccine safe? A vaccine, like any medicine, is capable of causing serious problems such as severe allergic reactions. Getting meningococcal vaccine is much safer than getting the disease. Some people who get meningococcal vaccine have mild side effects, such as redness or pain where the shot was given. These symptoms usually last for 1-2 days. A small percentage of people who receive the vaccine develop a fever. The vaccine can be given to pregnant women. Anyone who has ever had Guillain-Barré Syndrome should talk with their provider before getting meningococcal conjugate vaccine. Is it mandatory for students to receive meningococcal vaccine for entry into secondary schools or colleges that provide or license housing? Massachusetts law (MGL Ch. 76, s.15D) requires newly enrolled full-time students attending a secondary school (those schools with grades 9-12) or postsecondary institution (e.g., colleges) who will be living in a dormitory or other congregate housing licensed or approved by the secondary school or institution to receive meningococcal vaccine. At affected secondary schools, the requirements apply to all new full-time residential students, regardless of grade (including grades pre-K through 8) and year of study. All students covered by the regulations must provide documentation of having received a dose of meningococcal polysaccharide vaccine within the last 5 years (or a dose of meningococcal conjugate vaccine at any time in the past), unless they qualify for one of the exemptions allowed by the law. Whenever possible, immunizations should be obtained prior to enrollment or registration. However, students may be enrolled or registered provided that the required immunizations are obtained within 30 days of registration. Students may begin classes without a certificate of immunization against meningococcal disease if: 1) the student has a letter from a physician stating that there is a medical reason why he/she can’t receive the vaccine; 2) the student (or the student’s parent or legal guardian, if the student is a minor) presents a statement in writing that such vaccination is against his/her sincere religious belief; or 3) the student (or the student’s parent or legal guardian, if the student is a minor) signs the waiver below stating that the student has received information about the dangers of meningococcal disease, reviewed the information provided and elected to decline the vaccine. Where can a student get vaccinated? Students and their parents should contact their healthcare provider and make an appointment to discuss meningococcal disease, the benefits and risks of vaccination, and the availability of this vaccine. Schools and college health services are not required to provide you with this vaccine. Where can I get more information? Your healthcare provider The Massachusetts Department of Public Health, Division of Epidemiology and Immunization at (617) 983-6800 or www.mass.gov/dph/imm and www.mass.gov/dph/epi Your local health department (listed in the phone book under government)
Waiver for Meningococcal Vaccination Requirement I have received and reviewed the information provided on the risks of meningococcal disease and the risks and benefits of meningococcal vaccine. I understand that Massachusetts’ law requires newly enrolled full-time students at secondary schools, colleges and universities who are living in a dormitory or congregate living arrangement licensed or approved by the secondary school or postsecondary institution to receive meningococcal vaccinations, unless the students provide a signed waiver of the vaccination or otherwise qualify for one of the exemptions specified in the law.
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After reviewing the materials above on the dangers of meningococcal disease, I choose to waive receipt of meningococcal vaccine.
Student Name: ____________________________________________ Date of Birth: _________________ Student ID or SSN: ________________________________________________________________________ Signature: __________________________________________________ Date: _________________ (Student or parent/legal guardian, if student is under 18 years of age) Provided by: Massachusetts Department of Public Health / Division of Epidemiology and Immunization / 617-983-6800 MDPH Meningococcal Information and Waiver Form
Reviewed July 2014
