INSTRUCTIONS FOR COMPLETING THE HEALTH RECORD

Please print using black ink. Read carefully and fill in all applicable information.

Personal Information: To be completed by the student.

Complete all requested demographic information including the names of persons who could be contacted in case of an emergency. If you have a medical condition that requires ongoing care or treatment, ask your health care provider to send a summary record that includes any recommendations or precautions that the health center staff should follow:

Immunizations: To be completed by a Health Care Provider

  1. Meningococcal Vaccine: One dose of Menomune or Menactra or a signed waiver must be completed. The Haemophilus influenza type B (Hib) vaccine given to infants and young children does not protect against meningococcal disease and does not meet the vaccine requirement.
  2. MMR (Measles, Mumps,Rubella): Two doses are required. Dose 1 must be given on or after the first birthday. Dose 2 at least one month later.
  3. Tetanus Diphtheria: Completed primary series is required. A tetanus-diphtheria booster is required within 10 years of matriculation at RoanokeCollege. The tetanus-diphtheria-acellular pertussis (Tdap) is preferred.
  4. Tuberculosis Skin Test: A PPD test is required prior to arrival at RoanokeCollege if any of the statements on theTuberculosis RiskAssessment Formapply to you. This is regardless of prior BCG vaccination.Students arriving in the United States from other countries who are required to have a tuberculosis skin test must have the test done prior to starting classes. This test can be performed at the HealthCenter.

Any positive PPD, past or present, requires a current chest x-ray within six months prior to entrance to RoanokeCollege. A copy of this report, in English, must be sent with your health record. If the student’s skin test is positive, indicate whether or not treatment with INH (isoniazid) for at least six months has been received or initiated.

  1. Polio: Completed primary series (oral and/or injectable) is required. If only three doses were administered, one must be after the fourth birthday.
  2. Hepatitis B: A completed series of three doses or a signed waiver must be completed.

Recommended Immunizations:

Varicella (chicken pox) if no history of disease. One dose before age 13 or two doses if given after age 13.

Gardasil a cervical cancer vaccine for girls and women age 9-26. Works best if given before any contact with the human papilloma virus (HPV). Given as three injections over 6 months.