PRE-ENTRANCE HEALTH REQUIREMENTS CHECKLIST

Welcome! A number of forms must be completed and returned to the Mount Holyoke College Health Center no later than July 1, 2014 for Fall Entrants. Forms for Spring Entrants are due to the Health Center no later than December 1, 2014.

Please download the required forms. You and your health care provider must complete the forms. These forms cannot be completed online. Each file has one page of instructions and a form. These forms can be printed as either single or double-sided copies. When mailing the completed forms please do not include the instruction pages or staple any forms together.

You may also email the forms to health-services@mtholyoke.edu or fax to 413-538-2352.

Students entering or transferring to all Mount Holyoke College programs must meet all pre-entrance requirements.

□ Contact Information

□ Consent to Treat (If Date of Birth is after 08/26/1996)

□ *Medical History

□ *Physical Exam

□ *Immunization Record

□ *Tuberculosis Screening Form

□ Meningitis Waiver (See Instructions)

□ Sickle Cell Trait Form (Varsity and Club Athletes)

*Require signature of health care provider

If you are unable to download and print the forms we will mail them to you. To request forms, please email health-services@mtholyoke.edu and include your name and mailing address.

If you have questions about any of the requirements, you may email or call 413-538-2089.

THE PRE-ENTRANCE HEALTH REQUIREMENTS APPLY TO ALL INCOMING STUDENTS REGARDLESS OF THE PROGRAM THEY ARE ENTERING

Contact Information and Consent for Medical Care Instructions Please read these instructions before filling out the Contact Information and Consent for Medical Care

Contact Information: All students, regardless of age, must complete this section. Most communication with students will be via college assigned email address. Only in the case of a life-threatening emergency will parents/guardians be notified of a change in the student’s health status. Consent for Medical Care: The parents/guardians of students who have a date of birth after 08/15/1996 for Fall entrants and 01/15/1997 for Spring entrants must complete this section of the form.

Contact Information

Consent for Medical Care REQUIRED FOR ALL STUDENTS

Name __________________________________________________________________________Date of Birth__________________ Last First MI Month Day Year

Preferred Name _________________________________

Permanent Address ___________________________________________________________________________________________ Street

_____________________________________________________________________________________________________________________________________

City State Zip Code Country

Home Phone _________________________________________________Student Cell Phone ________________________________

Parent/Guardian/Next of Kin Information (for contact in case of emergency)

Name ________________________________________________________________Relationship ___________________________ Last First

Address ____________________________________________________________________________________________________ Street City State Zip Code Country

Home Phone _______________________________Business Phone ________________________ Cell Phone __________________

Alternate Emergency Contact

Name ________________________________________________________________Relationship ___________________________ Last First

Address ____________________________________________________________________________________________________ Street City State Zip Code Country

Home Phone _______________________________Business Phone ________________________ Cell Phone __________________

Consent for Medical Care Signature of Parent/Guardian required for students born after 08/15/1996. This signature is valid until student is age of 18.

I hereby grant permission to the Mount Holyoke College Clinician to provide medical care and mental health/substance abuse

counseling to my daughter while at Mount Holyoke College. _________

Initial

I hereby grant permission for the treatment, including hospitalization, anesthesia, or surgery of my daughter in the event of a

medical emergency or surgical emergency. This permission is in the event that I am not able to be contacted and medical or

surgical judgment indicates that further delay would represent a serious risk to her. _____________

Initial

I hereby grant permission to the Health Services of Mount Holyoke College to complete immunizations as required by

Massachusetts State Law or to give appropriate boosters or flu shots as deemed indicated by the Medical Director. ___________

Initial

I understand that I am financially responsible for care provided to my daughter. I understand an itemized statement is provided

to my daughter monthly. This statement will provide sufficient detail for me to submit to my insurance carrier. _____________

Initial

___________ _____________________________________________________________ ________________________

Date Signature Relationship

Due Date:

July 1, 2014-Fall Entrants

December 1, 2014-Spring Entrants

Pre-Entrance Medical History and Physical Form Instructions Please read these instructions before filling out the Medical History and Physical Forms

The Medical History and Physical forms must be completed and signed by your health care provider.

The date of the student’s last physical exam must be clearly noted on the Physical Form. The physical

exam must have been completed after 08/15/2013 for Fall entrants and 01/15/2014 for Spring entrants.

If the student will be participating in varsity or club sports, the exam must have been completed after

02/15/2014 for Fall entrants or 07/15/2014 for Spring entrants. Additional information regarding

chronic health conditions, surgery, or ongoing care should be provided in a separate letter.

Please note: The date of the physical exam must be noted on the Physical Exam form. Also, please be

sure that your health care provider completes the sport participation section even if you do not

currently plan to participate in sports.

Students who do not submit all required forms and complete all health requirements prior to practice

dates will not be allowed to participate in team practice.

Medical History-Student MUST complete this form. Health care provider must sign this form.

STUDENT NAME ______________________________________________________________DATE OF BIRTH _________________

FAMILY HISTORY RELATION AGE STATE OF

HEALTH AGE AT DEATH

CAUSE OF DEATH Have any of your Immediate relatives had the following:

No Yes Relationship

PARENT ALCOHOL/SUBSTANCE ABUSE PARENT CANCER SIBLING DIABETES SIBLING KIDNEY DISEASE SIBLING NEUROMUSULAR DISORDER SIBLING MENTAL/EMOTIONAL ILLNESS SPOUSE/PARTNER TUBERCULOSIS CHILD ASTHMA CHILD HEART DISEASE

PERSONAL HISTORY-Do you now have or have you ever had (check all that apply): ◊ None Apply

◊ Anxiety Disorder ◊ Depression ◊ Insomnia ◊ Seizure Disorder

◊ Anemia ◊ Diabetes ◊ Kidney Disease/Stones ◊ Sickle Cell Disease

◊ Appendectomy ◊ Disordered Eating ◊ Learning Disability/ADD/ADHD ◊ Skin Disorder

◊ Arthritis ◊ Emotional/Mental Illness ◊ Loss of paired organ (eye, kidney) ◊ Substance Abuse Disorder

◊ Asthma ◊ Heart Disease/Condition ◊ Malaria ◊ Thyroid Disease

◊ Blind/Visual Impairment ◊ Hepatitis (Type_____) ◊ Migraines/Chronic Headache ◊ Sexually Transmitted Infection

◊ Cancer/Malignancy ◊ High Blood Pressure ◊ Mononucleosis ◊ Tuberculosis Disease

◊ Concussion ◊ High Cholesterol ◊ Neuromuscular Disease ◊ Ulcer/Stomach Problem

◊ Crohn’s/Ulcerative Colitis ◊ HIV Infection/disease ◊ Phlebitis/Deep Vein Clot ◊ UTI’s (frequent/recurrent)

◊ Deaf/Hearing Impairment ◊ Impaired Mobility/Paralysis ◊ Pneumonia

PLEASE EXPLAIN ALL POSITIVE ANSWERS (with dates/additional pages if needed):

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

INPATIENT HOSPITALIZATIONS (please list all medical and/or psychiatric hospitalizations and surgical procedures with dates and diagnoses):

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

MENSTRUAL HISTORY Age of onset: _____________ Frequency: ________________ Duration: _______________________

History of irregularity: ________________________________________________________________ Medication: _____________________

1. Do you exercise? ◊ Never ◊ Occasionally ◊ 3-5 times/week ◊ Daily

What type of exercise? ______________________________________

2. What is your desired weight? ____________lbs

3. Would you describe your weight as? ◊ Underweight ◊ Overweight

◊ Just Right

4: Do you limit or control what you eat? ◊ No ◊ Yes

5. How much caffeine do you consume daily? ____________________________

6. Do you wear a seatbelt? ◊ Always ◊ Sometimes ◊ Never

7. Do you smoke cigarettes? ◊ No ◊ Yes. How many/day__________

8. Do you use recreational drugs? ◊ No ◊ Yes. Which ones?

___________________________________________________________________

9. Do you drink alcohol? ◊ No ◊ Yes. How often? ___________

10. Are you concerned about your drinking or drug use? ◊ No ◊ Yes

11. Do you often feel anxious, overwhelmed, hopeless, or depressed? ◊ No ◊ Yes

12. Have you ever received psychiatric treatment or psychological counseling? ◊ No ◊ Yes

13. Have you intentionally harmed or tried to hurt yourself? ◊ No ◊ Yes

Due Date: July 1, 2014-Fall Entrants December 1, 2014-Spring Entrants

Reviewed By: ___________________________________________________________________Date: ___________________________________

Print Name: _______________________________________________________Phone: _______________________________________________

Address: _______________________________________________________________________________________________________________ HEALTH CARE PROVIDER SIGNATURE REQUIRED

Mandatory Physical Exam The date of the last physical exam must have been AFTER 08/15/2013 for Fall Entrants and 01/15/2014 for Spring Entrants

Please note: Physical for Varsity and Club Athletes must be after 02/15/2014 for Fall Entrants and 07/15/2014 for Spring Entrants

Date of Exam______________

***Please complete the sports section below even if student does not currently plan to participate in sport activity***

May participate in competitive sports (check one): � Contact/Collision � Limited Contact � Non-Contact

Comments: _____________________________________________________________________________________________________________________________ STUDENT NAME ____________________________________________________________________Date of Birth _______________

Height: ______ft _______in Weight _______lbs. BP: R arm ____ /_____ and L arm _____ /______ Pulse _________

Please answer all questions and provide all physical data requested on the form. YES NO Prior exertional chest pain Prior exertional syncope/near syncope Excessive, unexplained shortness of breath or fatigue with exercise Prior history of heart murmur or elevated blood pressure Family history of premature death from cardiovascular disease in a relative younger than 50 Occurrence in family of hypertrophic cardiomyopathy or dilated cardiomyopathy, long QT or Marfan’s syndrome

System Record Result Describe Abnormality Heart/Vascular system (Describe murmur, click) Precordial Auscultation in both supine and standing positions to identify murmurs consistent with dynamic left ventricular outflow obstruction

Assessment of femoral artery pulses to exclude coarctation of the aorta Presence of physical stigmata of Marfan’s Syndrome Skin HEENT Lungs/Chest Abdomen (rectal if indicated) Musculoskeletal Neurological Other Significant Findings

Lab work recommended Hgb/Hct _____________ Cholesterol _____________HDL _____________LDL_____________

Is student being treated for a chronic/ongoing medical or orthopedic condition or a serious illness? ◊ No ◊ Yes, IF YES, PLEASE PROVIDE A

SEPARATE LETTER WITH PERTINENT HISTORY AND ONGOING TREATMENT PLAN TO ASSIST US IN PROVIDING CONTINUITY OF CARE.

ALLERGIES (medications, insect venom, foods) __________________________________________________________________________________

Type of reaction ______________________________________________________________ Does the student have an Epi-Pen? ◊ Yes ◊ No

CURRENT MEDICATIONS (include prescription, non-prescription and supplements): ________________________________________________________________________________________________________________________

Do you have any dietary recommendations? ◊ No ◊ Yes. Please specify: ______________________________________________________

Please note any additional recommendations regarding this student: ________________________________________________________________ ________________________________________________________________________________________________________________________

Due Date: July 1, 2014-Fall Entrants December 1, 2014-Spring Entrants

Health care provider: _______________________________________________________________________________ Address: __________________________________________________________________________________________ Phone: _________________________________ Fax: _____________________________________ Provider’s signature: ___________________________________________________________ Date: _______________

Health Care Provider Signature Required

Immunization Record Instructions and Form Please read these instructions before filling out the Immunization Record Form

Immunizations on Page 1 are REQUIRED for all students entering Mount Holyoke College

Immunizations listed on Page 2 are not required but RECOMMENDED

A. Tetanus, Diphtheria, Pertussis – One dose of the vaccine is required by Massachusetts State Law 1. One dose of Tdap is required for all incoming students regardless of the date of the last tetanus containing vaccine.

If the Tdap vaccine is not available in your country, defer this immunization until the student’s arrival on campus.

A.II Dates of Primary series of Tetanus-Diphtheria

B. Measles, Mumps, Rubella – Two doses of the vaccine are required by Massachusetts State Law 1. 1st dose given after 12 months of age 2. 2nd dose given at least one month after the 1st dose 3. Positive Measles, Mumps, Rubella lab titer must be included if dates of immunization are not available

If the student was born before 1957, this Immunization is not required. 4. Please use Section B II to document any Monovalent Measles, Mumps, and Rubella vaccines

Please note that a physician history of having had the diseases of Measles, Mumps, or Rubella does not meet the Massachusetts state requirement. Only laboratory documentation (titer) showing immunity is acceptable in Massachusetts.

C. Hepatitis B – Three doses of the vaccine are required by Massachusetts State Law 1. 1st dose given at an elected date 2. 2nd dose given one month after the 1st dose 3. 3rd dose given at least 4-6 months after the 1st dose and 8 weeks after the 2nd dose 4. The adolescent dose schedule given between the ages of 11 and 15 may be accepted. The dosage must be specified 5. Combined dose of Hepatitis A/B. Using the same dosing schedule as Hepatitis B 6. Positive Hepatitis B lab titer must be included if dates of immunization are not available

D. Meningitis Immunization/Waiver – Required by Massachusetts State Law 1. MCV4-Tetravalent Conjugate Vaccine (Menatra or Menveo) or MPSV4-Tetravalent Polysaccharide Vaccine (Menomune)

given within the last five years Fall Entrants—08/15/2009 and Spring Entrants 01/15/2010 OR

2. Waiver Form – Must be completed and signed after reviewing the Massachusetts Department of Health Meningococcal Information and Waiver Form

E. Varicella Vaccine or proof of immunity – Required by Massachusetts State Law 1. A physician documented history of the Chicken Pox with the date the student had the disease must be included-OR- 2. Positive Varicella titer-lab report must be included if dates of disease are unavailable-OR- 3. Two doses of the Varicella immunization

a. 1st dose given after 12 months of age b. 2nd dose given at least 1 month after the 1st dose-OR-

4. If you were born before 1980, this immunization is not required

For more information on Massachusetts requirements please refer to the following links: http://www.mass.gov/eohhs/docs/dph/cdc/immunization/guidelines-ma-school-requirements.pdf

Students requesting a medical exemption from the immunization requirements must provide documentation from their health care provider. If a student would like to request a religious exemption, please send an explanatory note to request religious exemption. Massachusetts State Law requires students who have not been immunized to leave campus should an outbreak occur. Students identified as contacts who do not meet the immunization requirements will be isolated or required to leave the campus for up to three weeks.

Additional information regarding MGL Chapter 76, Sec. 15 and 15d can be found at: http://www.state.ma.us/legis/laws/mgl/mgllink.htm

Immunization Record-Page 1 Massachusetts State Law requires proof of immunity prior to matriculation. Please use this form to record immunization dates. International students must provide an English transcript of immunization history. NAME_________________________________________________________________________________________________________________ Last First Middle Date of Birth

REQUIRED IMMUNIZATIONS Massachusetts State Law requires all immunizations on Page 1

A Tetanus, Diphtheria, Pertussis-Tdap **Date of Immunization Required**

Tdap: ______/______/______ Mo Day Year

B Measles, Mumps, Rubella (MMR)-Two doses Required

**Dates of Immunizations or Proof of Immunity Required** *See Page 2 for Monovalent Measles, Mumps, Rubella*

MMR #1: ______/______/______(After 12 months of age) MMR #2: ______/______/______ (At least 1 month after dose 1)

Mo Day Year Mo Day Year

OR

◊ Exempt (born before 1957) ◊ Positive Lab Titers (Lab reports MUST be included)

C Hepatitis B (Three doses Required) or A/B **Dates of Immunizations or Proof of Immunity Required**

Hepatitis B Hepatitis A/B

◊ Positive Lab Titers (Lab Reports MUST be included)

Dose #1: ______/______/______

*Any Elected Date*

Dose #1: ______/______/______

*Any Elected Date*

Dose #2: ______/______/______ *At least 28 days after Dose #1*

Dose #2: ______/______/______ *At least 28 days after Dose #1*

Dose #3: ______/______/______

*At least 4 months after 1st Dose and 8 weeks after 2nd Dose*

Dose #3: ______/______/______

*At least 4 months after 1st Dose and 8 weeks after 2nd Dose*

D Meningitis Immunization/Waiver

*Must have been administered within the past five years—Fall Entrants 08/15/2009---Spring Entrants 01/15/2010* **Date of Immunization or Signed Waiver Required**

◊ MCV4 (Menactra or Menveo): ______/______/______ ◊ MPSV4 (Menomune): ______/______/______

Mo Day Year Mo Day Year

OR

◊ Waiver Signed

E Varicella Vaccine/Chicken Pox History **Date of Immunizations, Positive History of Chicken Pox, or Proof of Immunity Required**

◊ Positive History of Disease ______/______/______(MUST include date of disease) ◊ Positive Lab Titers (Lab reports MUST be included)

Mo Day Year ◊ Exempt (born before 1980)

OR

Varicella #1: ______/______/______(After 12 months of age) Varicella #2: ______/______/______ (At least 1 month after dose 1) Mo Day Year Mo Day Year

Health care provider signature or stamp-REQUIRED

SIGNATURE ________________________________________________________________________________________________________________________

Due Date: July 1, 2014-Fall Entrants December 1, 2014-Spring Entrants

Immunization Record-Page 2 Massachusetts State Law requires proof of immunity prior to matriculation. Please use this form to record immunization dates. International students must provide an English transcript of immunization history. NAME_________________________________________________________________________________________________________________ Last First Middle Date of Birth

A II Tetanus-Diphtheria: Date of Primary Series (DTaP/DTP, Td)

Complete Primary Series (DPT, DTaP, Td) ◊ Yes ◊ No

Dose #1: ______/______/______ Vaccine Received ◊ DTaP ◊ DTP ◊ Td Dose #2: ______/______/______ Vaccine Received ◊ DTaP ◊ DTP ◊ Td Mo Day Year Mo Day Year

Dose #3: ______/______/______ Vaccine Received ◊ DTaP ◊ DTP ◊ Td Dose #4: ______/______/______ Vaccine Received ◊ DTaP ◊ DTP ◊ Td Mo Day Year Mo Day Year

H Polio

Complete Primary Series of Polio Immunization ◊ Yes ◊ No

Dose #1: ______/______/______ Vaccine Received ◊ OPV ◊ IPV ◊ E-IPV Dose #2: ______/______/______ Vaccine Received ◊ OPV ◊ IPV ◊ E-IPV Mo Day Year Mo Day Year

Dose #3: ______/______/______ Vaccine Received ◊ OPV ◊ IPV ◊ E-IPV Dose #4: ______/______/______ Vaccine Received ◊ OPV ◊ IPV ◊ E-IPV Mo Day Year Mo Day Year

I Human Papilloma Virus Recombinant Vaccine (HPV2, HPV4)--**RECOMMENDED**

HPV #1: ______/______/______ HPV #2: ______/______/______ HPV #3: ______/______/______ Mo Day Year Mo Day Year Mo Day Year

J Hepatitis A--**RECOMMENDED**

Hepatitis A #1: ______/______/______ Hepatitis A #2: ______/______/______ Mo Day Year Mo Day Year

K Pneumococcal Polysaccharide Vaccine—**RECOMMENDED** For High Risk Groups

Date of Dose: ______/______/______ Mo Day Year

B. II Monovalent Measles, Mumps, Rubella **Dates of Immunizations or Proof of Immunity Required**

Measles Mumps Rubella

Dose #1: ______/______/______ *must be after 12 months of age*

Dose #1: ______/______/______ *must be after 12 months of age*

Dose #1: ______/______/______ *must be after 12 months of age*

Dose #2: ______/______/______

*must be at least 1 month after dose 1*

Dose #2: ______/______/______

*must be at least 1 month after dose 1*

Dose #2: ______/______/______

*must be at least 1 month after dose 1*

Health care provider signature or stamp-REQUIRED SIGNATURE ________________________________________________________________________________________________________________________

Due Date: July 1, 2014-Fall Entrants December 1, 2014-Spring Entrants

Tuberculosis Screening Instructions

Please read these instructions before filling out the Tuberculosis Screening Form

Section 1 – Prior Immunization and Testing **All Questions must be completed** A. If the student received BCG, provide the dates of immunization. A history of BCG Immunization

does not preclude PPD Testing. B. If the student answered “NO” to Part B proceed to Section 2. C. If the student answered “YES” to Part B – DO NOT repeat the PPD test. Please have the health

care provider complete Section 4. Section 2 – Risk Assessment Questionnaire **All Questions must be completed**

A. If the student answers “YES” to any of the questions in Section 2, proceed to Section 3. The student is required to have Tuberculin skin test or blood test.

B. If the student answers “NO” to all questions in Section 2, no testing is required. Health care provider must review and sign the Tuberculosis Screening Form.

Section 3 – Medical Evaluation of Student for Latent Tuberculosis Infection A. When performing the Tuberculin Skin Test, health care providers must use 5 TU Mantoux (Intermediate

PPD) only. I. Please provide the date the PPD test was planted, the date the PPD was read, and the mm of

induration in horizontal diameter. II. Complete the risk-based assessment. If the student had a positive PPD, further testing is required III. The following blood tests will be accepted in place of skin testing:

a) Quantiferon-Gold test b) Quantiferon-Gold in-tube test c) T-Spot.TB

All testing must be done in the United States or Canada. The tests must have been completed after 08/15/2013 for Fall entrants and 01/15/2014 for Spring entrants. When indicated, TB testing will be performed at the Mount Holyoke College Health Center during orientation for students arriving from areas outside the United States or Canada. Section 4 – Chest X-Ray

A. If a student requires a chest X-Ray, ONLY X-Ray’s performed in the United States or Canada will be accepted. Only X-Ray’s performed after 08/15/2013 for Fall entrants and 01/15/2014 for Spring entrants will be accepted.

B. If a student has had a positive PPD in the past but was not treated, a chest x-ray is required within the last 12 months.

When indicated, Mount Holyoke College will perform chest X-Rays for students coming from outside the United States or Canada.

Section 5 – Treatment A. If a student has active tuberculosis, treatment is required. Treatment is recommended for those

students with a latent tuberculosis infection. If the student is being treated for active tuberculosis or latent tuberculosis infection, please provide the drug, dosage, frequency, and dates.

Your health care provider must complete and sign the Tuberculosis Screening Form

Tuberculosis Screening (Page 1) Date of Visit______________

NAME___________________________________________________________________________________________ LAST FIRST MIDDLE DATE OF BIRTH

Section 1: Prior Immunization and Testing **REQUIRED**

A. Has student received the BCG immunization? ◊ Yes ◊ No If yes, please give dates of immunization: ________________________

History of BCG does not preclude PPD Testing B. Has student ever had a positive tuberculosis skin test? ◊ Yes ◊ No

If no, Proceed to Section 2 If yes, DO NOT repeat PPD Testing. Health Care Provider must complete Section 4

Section 2: Risk Assessment Questionnaire **REQUIRED**

A. To the best of your knowledge, has student ever had close contact with anyone who was sick with tuberculosis? ◊ Yes ◊ No

B. Was the student born in one of the countries with high rates of TB listed on Page 2? ◊ Yes ◊ No

C. Has student traveled or lived for more than one month in any of the countries listed on Page 2? ◊ Yes ◊ No

If the answer to ANY of the questions in Section 2 is “Yes,” student is required to have a tuberculin skin test or blood test. (See Section 3) If ALL answers are “No” testing should not be done

Section 3: Medical Evaluation/TB Testing **Required if student answered “Yes” to questions in Section 2**

*ONLY TESTING COMPLETED IN THE US OR CANADA ACCEPTED* Testing MUST have been completed after 08/15/2013 for Fall entrants and 01/15/2014 for Spring entrants

TUBERCULIN SKIN TEST: Use 5 TU Mantoux (Intermediate PPD) ONLY

Date PPD planted: ______/______/______ Date PPD read: ______/______/______ Mo Day Year Mo Day Year

Result of PPD: ________mm of induration in horizontal diameter

Risk based interpretation ◊ Positive (Complete Section 4, if positive) ◊ Negative

Interferon Gamma Release Assay: Attach Lab Results. If Positive, complete Section 4

Section 4: Chest X-Ray *ONLY TESTING COMPLETED IN THE US OR CANADA ACCEPTED*

Testing MUST have been completed after 08/15/2013 for Fall entrants and 01/15/2014 for Spring entrants

Chest X-Ray (Required) ______/______/______ ◊ Normal ◊ Abnormal Mo Day Year

Section 5: Treatment *REQUIRED for active Tuberculosis, recommended for latent Tuberculosis infections*

Treatment ◊ No ◊ Yes Date Treatment Started:________________________

Drug: ______________________ Dose _________________ Frequency: __________________

**Please attach treatment schedule with date and medications**

Reviewed By: ____________________________________________________________________________________________Date: _______________________ Print Name: ___________________________________________________________Phone: ________________________________________________________ Address: _____________________________________________________________________________________________________________________________

HEALTH CARE PROVIDER SIGNATURE OR STAMP REQUIRED

Due Date: July 1, 2014-Fall Entrants December 1, 2014-Spring Entrants

Tuberculosis Screening (Page 2)

COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)* *World Health Organization Global Tuberculosis Database 2012

Afghanistan Colombia Iraq Namibia South Africa Albania Comoros Japan Nauru South Sudan Algeria Congo Kazakhstan Nepal Sri Lanka Andorra Congo DR Kenya New Caledonia Sudan Angola Cote d’lvoire Kiribati Nicaragua Suriname Anguilla Djibouti Korea-DPR Niger Swaziland Argentina Dominica Korea-Republic Nigeria Syrian Arab Republic Armenia Dominican Republic Kuwait Niue Tajikistan Azerbaijan Ecuador Kyrgyzstan N. Mariana Islands Tanzania-UR Bahrain Egypt Lao PDR Pakistan Thailand Bangladesh El Salvador Latvia Palau Timor-Leste Belarus Equatorial Guinea Lesotho Panama Togo Belize Eritrea Liberia Papua New Guinea Tonga Benin Estonia Libya Paraguay Trinidad Tobago Bhutan Ethiopia Lithuania Peru Tunisia Bolivia Fiji Macedonia-TFYR Philippines Turkey Bosnia & Herzegovina French Polynesia Madagascar Poland Turkmenistan Botswana Gabon Malawi Portugal Turks & Caicos Islands Brazil Gambia Malaysia Qatar Tuvalu Brunei Darussalam Georgia Maldives Romania Uganda Bulgaria Ghana Mali Russian Federation Ukraine Burkina Faso Greenland Marshall Islands Rwanda Uruguay Burundi Guam Mauritania St. Vincent & The Grenadines Uzbekistan Cambodia Guatemala Mauritius Samoa Vanuatu Cameroon Guinea Mexico Sao Tome & Principe Venezuela Cabo Verde Guinea-Bissau Micronesia Senegal Viet Nam Central African Republic Guyana Moldova-Rep Serbia Wallis & Futuna Islands Chad Haiti Mongolia Seychelles Yemen Chile Honduras Morocco Sierra Leone Zambia China Hungary Montenegro Singapore Zimbabwe China, Hong Kong SAR India Mozambique Solomon Islands China, Macao SAR Indonesia Myanmar Somalia Iran

Risk-Based Interpretation of Tuberculin Skin Test

RISK FACTOR POSITIVE RESULT

Close contact with a case of Tuberculosis 5mm or more

Born in a country that has a high rate of Tuberculosis

Traveled or lived for one month or more in a country that has a high rate of Tuberculosis

10 mm or more

None (test not recommended) 15 mm or more

Mount Holyoke College Sickle Cell Trait Form for Varsity and Club Sports

About Sickle Cell Trait • Sickle Cell Trait is not a disease. Sickle Cell Trait is an inherited condition affecting the oxygen-carrying substance,

hemoglobin, in the red blood cells. You are born with sickle cell trait; it cannot be developed over time or contracted like a disease.

• Sickle Cell Trait is a common condition (> three million Americans.) • Although Sickle Cell Trait occurs most commonly in African-Americans and those of Mediterranean, Middle Eastern, Indian,

Caribbean, and South and Central American ancestry, persons of all races and ethnicities may test positive for this condition. • Those with Sickle Cell Trait usually have no symptoms or any significant health problems. However, sometimes during very

intense, sustained physical activity, as can occur with collegiate sports, certain dangerous conditions can develop in those with Sickle Cell Trait, leading to blood vessel and organ (kidneys, muscles, heart) damage that can cause sudden collapse and death. Some of the settings in which this can occur include timed runs, all out exertion of any type for 2 to 3 continuous minutes without a rest period, intense drills and other bursts of exercise after doing prolonged conditioning training. Extreme heat and dehydration increase the risks.

• More information and resources regarding Sickle Cell Trait and the NCAA’s recommendation for Sickle Cell Trait testing can be found at the NCAA website resource pages regarding Sickle Cell Trait, accessible at:

http://www.ncaa.org/health-and-safety/medical-conditions/sickle-cell-trait http://www.ssilearn.org/

Sickle Cell Trait Testing • The NCAA recommends that all student-athletes have knowledge of their Sickle Cell Trait status. Student-athletes must

complete one of the following: 1. Show proof a prior test results. – OR – 2. Have a blood test to check for Sickle Cell Trait – OR – 3. Sign a testing waiver declining options 1 and 2

Whichever option is chosen, it must be completed before the athlete participates in any intercollegiate athletic events, including strength and conditioning sessions, practices, competitions, etc.

• Athletes who are positive for the Trait will be allowed to participate in intercollegiate athletics; this does NOT prohibit you from playing.

One of the following options MUST be chosen. Please select one and include ALL required documentation:

� Copy of athlete’s newborn sickle cell testing result ATTACHED: Date: ______________________

Most states require testing at birth, check with your hospital or pediatrician

� Copy of recent Sickle Cell screening test result ATTACHED: Date: ______________________ Cost of testing is the responsibility of the athlete

� SICKLE CELL TESTING WAVIER:

By signing this waiver, I understand and acknowledge that the NCAA recommends that all Student-Athletes have knowledge of their Sickle Cell Trait status. Additionally, I certify that I have read and fully understand the aforementioned facts and I have had the opportunity to review the NCAA website for further information about Sickle Cell Trait and Sickle Cell Trait testing.

I DO NOT wish to undergo Sickle Cell Trait testing and I voluntarily agree to release, discharge, indemnify and hold harmless, Mount Holyoke College, it officers, employees, agents and their successors and assigns from any and all costs, claims, damages or expenses, including attorney’s fees, arising from any loss or personal injury that might result from my refusal to be tested.

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. ______________________________________________ __________________________________ ____________________

Athletes Signature Athlete’s Name Printed Date ______________________________________________ __________________________________ ____________________ Parent/Guardian’s Signature (if under 18 years of age) Parent/Guardian’s Name Printed Sport

(See reverse side)

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).

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.

□ 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 March 2013