Primary Care Health Service Incoming Student Immunization Information PRIMARY CARE HEALTH SERVICE LOWER LEVEL – BROOKS HALL 3009 BROADWAY, NEW YORK, NY 10027 PHONE: 212.854.2091 FAX: 212.854.2702 For questions please email Stephanie Paciulla at [email protected] THESE FORMS MUST BE SUBMITTED BY JUNE 30, 2012 REQUIRED VACCINATIONS PRIOR TO ARRIVAL AT BARNARD The vaccinations and/or proofs of immunity for MMR and the completion of the Meningitis Response form are required by New York State Public Health Laws 2165 and 2167. No student will be permitted on campus, or to attend the institution, without compliance. Please print out the next several pages, bring them to your health care provider to document your immunity from measles, mumps and rubella. If you have had a meningococcal meningitis vaccination, you will need to provide relevant documentation. Please have all dates in the mm/dd/yyyy format Part I: Date _________________ Birth Date ___________________ Name Last First M Address City, State, Zip Part II: - TO BE COMPLETED & SIGNED BY YOUR HEALTH CARE PROVIDER. All information must be in English. A. M.M.R. (Measles, Mumps, Rubella) (Two doses or titers mandated by NYS law) 1. Dose 1 Must have been given no earlier than 4 days before 1st birthday (Date:) 2. Dose 2 given at age 4-6 years or later but not less than 28 days after first dose (Date:) (Please complete only if applicable) Result: Positive Negative 3. Date of Measles Titer Date of Mumps Titer _________________________ Result: Positive Negative Result: Positive Negative Date of Rubella Titer 1 of 3 Rev. 4/2012 Primary Care Health Service B. TUBERCULOSIS SCREENING: Please answer the following questions: 1. Have you ever had a positive TB skin test? Yes No 2. Have you ever had close contact with anyone who was sick with TB? Yes No 3. Were you born in one of the countries listed below and arrived in the U.S. within the past 5 years? (If yes, please CIRCLE the country) Yes No 4. Have you ever traveled (for at least one month)* to/in one or more of the countries listed below? (If yes, please CIRCLE the country/ies) Yes No * The significance of the travel exposure should be discussed with a health care provider and evaluated Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad China Colombia Comoros Congo Cook Islands Côte d'Ivoire Croatia Democratic People's Republic of Korea Democratic Republic of the Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia French Polynesia Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iraq Japan Kazakhsta Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lesotho Liberia Libyan Arab Jamahiriya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia (Federated States of) Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nepal Nicaragu Niger Nigeria 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 and Principe Senegal Serbia Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe Source: W orld Health Organization Global Health Observatory Tuberculosis Incidence 2009. Countries with incidence rates of ≥ 20 cases per 100,000 population. For future updates, refer to http://apps.who.int/ghodata/?vid=510 If the answer is YES to any of the above questions, Barnard College requires a PPD or Mantoux test. A chest x-ray is required if the tuberculin skin test is positive. Date PPD Test Administered:_________________ Date PPD Test Read:_________________ Result: Positive Negative AND _________mm induration Date of Chest X-ray: __________________ Result: Normal Abnormal If the answer to all of the above questions is NO, no further testing or further action is required. 2 of 3 Primary Care Health Service RECOMMENDED VACCINATIONS PRIOR TO ARRIVAL AT BARNARD C. HEPATITIS A Dose#1 or Hepatitis A Titer: Date_ HEPATITIS B Dose#1_ _Dose#2 Result Positive Negative Dose#2 Dose#3 _Result Positive  Negative Hepatitis B Titer: Date_ D. VARICELLA (CHICKEN POX) Dose#1__________________Dose#2__________________ or Varicella Titer: Date_ Result Positive Negative If you had the disease, when did you have it? ______________________ or E. TETANUS-DIPHTHERIA-PERTUSIS (Primary series with DTaP or DTP and booster with Td in the last ten years meets requirement. ) Primary series of four doses with DTaP or DTP: Completed Basic Series:  Yes No Tdap (date of most recent booster) F. POLIO (Primary series in childhood meets requirement; three primary series schedules are acceptable) Completed Basic Series? Yes No Last Polio Booster date_ G. HPV VACCINE (dates for each one) #1 #2 #3 HEALTH CARE PROVIDER’S INFORMATION: (Please note that the only acceptable signatures are that of a physician, physician assistant or nurse practitioner.) ___________________________ Provider’s Name __________________________________________ Provider’s Signature Place Provider Stamp Here ____________________________________________________ Provider’s Address ____________________________________________________ Provider’s Telephone and Fax Numbers ______________________ Date 3 of 3