Student Health Services 900 University Avenue Riverside, CA 92507 Campushealth.ucr.edu Incoming Student Health Form 2015-2016 Academic Year Student Information - Enter the information in this section before printing this form.................................................... Personal Information Student ID #: Last Name First Name Address City Undergraduate Date of Birth Age at Enrollment Country Zip Code State Telephone Student Status International Student Initial Emergency Telephone Gender Qtr/Yr Entering Graduate Professional Tuberculosis Screening Questionnaire (to be completed by the student) Have you ever had a positive TB skin test? Yes No Have you ever had close contact with anyone who was sick with TB? Yes No Have you ever been vaccinated with BCG (tuberculosis vaccine)? Yes No Were you born in any of the countries listed below and arrived in the U.S. within the last 5 years? If yes, please CIRCLE the country below. Yes No Have you traveled to/in any of the countries listed below? If yes, please CHECK the country or countries below. Yes No 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 Columbia Comoros Congo Cook Islands Cote d'Ivoire Croatia Democratic People's Republic of Korea Democratic Republic of 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 Kazakhstan Kenya Kiribati Kuwait Kyrgystan Lao People's Democratic Republic Latvia Lesotho Liberia Libyan Arab Jamahiriya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia (Federated States) Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nepal Nicaragua 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 Former Yugoslav Republic of Macedonia Timor-Leste Togo Tongo Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe IF THE ANSWER IS YES TO ANY OF THE ABOVE QUESTIONS, UC RIVERSIDE REQUIRES THAT A LICENSED HEALTHCARE PROVIDER COMPLETE THE TUBERCULOSIS RISK ASSESSMENT ON THE FOLLOWING PAGE. THE TUBERCULOSIS RISK ASSESSMENT MAY BE MAILED ALONG WITH PROOF OF IMMUNIZATIONS (THE SUPPLIED FORM OR A COPY OF YOUR OFFICIAL IMMUNIZATION RECORD). IF YOU ANSWER NO TO ALL OF THE ABOVE QUESTIONS, PLEASE DISREGARD THE TUBERCULOSIS RISK ASSESSMENT AT THE BOTTOM OF THE FOLLOWING PAGE. Page 1 of 2