Medical

Mail/Fax this form to: Florida Atlantic University Student Health Services Immunization Office 777 Glades Road, Bldg. SU 80, Rm. 114 Boca Raton, FL 33431 Phone: (561) 297-0049 Fax: (561) 297-2769 Immunization Policy Pursuant to Florida Board of Governors Regulation 6.001(9), prior to registration, each student accepted for admission at Florida Atlantic University must submit a signed FAU Immunization Form. Florida Atlantic University requires documented proof of immunizations to measles and rubella. In addition, pursuant to Florida Board of Governors Regulations 6.007, effective July 1, 2008, all new matriculating students must also provide documentation of vaccinations against meningococcal meningitis and hepatitis B or provide a signed waiver for each declined vaccination. Acceptable documentation is as follows: MEASLES (RUBEOLA): Students can be considered compliant for measles only if they have official documentation of at least one of the following: 1. Immunization with TWO (2) DOSES of live measles virus vaccine* on or after the first birthday and at least 28 days apart. Persons vaccinated with killed or unknown vaccine prior to 1968 must be revaccinated. 2. Laboratory (serologic) evidence of measles immunity. 3. A written, dated statement, signed by a physician on his/her stationery, that specifies the date seen and stating that the person has had an illness characterized by a generalized rash lasting three (3) or more days, a fever of 101 degrees Fahrenheit or greater, a cough and conjunctivitis, and, in the physician’s opinion, is diagnosed to have had the 10-day measles (rubeola). RUBELLA (GERMAN MEASLES): Students can be considered compliant for rubella only if they have official documentation of at least one of the following: 1. Immunization with one (1) dose live rubella virus vaccine* on or after the first birthday. 2. Laboratory (serologic) evidence of rubella immunity. * PLEASE NOTE: ALL FEMALE STUDENTS SHOULD BE AWARE THAT THEY SHOULD NOT BE VACCINAT ED WITH A LIVE VIRUS VACCINE IF THERE IS ANY POSSIBILITY OF PREGNANCY. HEPATITIS B: Students can be considered compliant for hepatitis B only if they have documentation of at least one of the following: 1. Official documentation of immunization with THREE (3) DOSES of hepatitis B vaccine in accordance with the CDC Advisory Committee on Immunization Practices. 2. Laboratory (serologic) evidence of hepatitis B immunity (positive hepatitis surface antibody). 3. A signed waiver declining the vaccine (See Section B). MENINGOCOCCAL MENINGITIS: Students can be considered compliant for meningitis only if they have documentation of at least one of the following: 1. Documentation of immunization with ONE (1) DOSE of meningococcal meningitis vaccine. 2. A signed waiver declining the vaccine (See Section B). Additional Information: • Religious or medical exemptions – Contact the FAU Immunization Office for information. • In the event of a measles/rubella or meningococcal meningitis emergency, exempted students will be excluded from all classes and other campus activities until such time as is specified by the County Health Unit director/administrator or the Director of FAU Student Health Services. In order to be considered official, this form must contain a signature of authorizing person AND an office stamp. Copies of official records may be attached and must include the student’s name and front cover of all documents. Any changes, additions, writeovers, use of different ink/handwriting or use of white-out must be re-signed by the authorizing person providing proof. We reserve the right to interpret the validity of all documents. Immunization Form MANDATORY You will not be allowed to register without completion of this form and proof of immunity. www.fau.edu/shs Please keep a copy for your records. ( ) Rev. Date 04/2013 MMR (Measles/Mumps/Rubella) Dose (date): 1 ______/______/______ 2 ______/______/______ or Measles (Rubeola - live) Positive Titer Date Dose (date): 1 ______/______/______ 2 ______/______/______ or ______/______/______ and Rubella (German Measles): Positive Titer Date Date ______/______/______ or ______/______/______ Therapeutic Name: Last First MI Student ID Number (Z Number) Birth Date Sex Permanent Address Apt. City State Zip Code Phone A. Immunizations Required for Students born after 12/31/56. B. Requirements for ALL Students C. RECOMMENDED FOR ALL STUDENTS BUT NOT REQUIRED Immunization Date Positive Titer Date TB skin test (PPD): _____/_____/_____ Mumps: ______/______/______ ______/______/______ mm of induration: ____ Pos:____ Neg:___ Chicken Pox (varicella): ______/______/______ ______/______/______ TB treatment dates (if applicable): Td (most recent booster): ______/______/______ Prophylactic INH: ____/____/____ to ____/____/____ Polio (most recent dose): ______/______/______ Treatment: ____/____/____ to ____/____/____ PHYSICIAN OR AUTHORIZED SIGNATURE (MANDATORY) DATE OFFICE STAMP (MANDATORY) D. SIGNATURE REQUIRED BY ALL STUDENTS REGARDLESS OF AGE AND SIGNED BY PARENT/GUARDIAN IF STUDENT IS UNDER 18 I HAVE READ AND UNDERSTAND THE IMMUNIZATION REQUIREMENTS ON THIS FORM. Florida Atlantic University provides primary medical care through Student Health Services. If I require medical care, it is my responsibility to make an appointment and to provide copies of pertinent medical records as necessary. A complete health history will be obtained at the time of my clinic visit. STUDENT SIGNATUR E (MANDATORY ) DATE Medical consent for minors (if student is under 18) I concur with the above and authorize FAU Student Health Services to employ diagnostic procedures and render any treatment or care deemed necessary to the health and well-being of my student. I grant permission for the transfer of my student to an accredited hospital or other care facility if deemed necessary by the medical provider. SIGNATURE OF PARENT/GUARDIAN (If student is under 18.) DATE I have received detailed information about meningococcal meningitis and hepatitis B and the potential fatal nature of meningococcal meningitis, as well as the risks associated with hepatitis B and the availability, effectiveness, and known contradictions of any required or recommended vaccines. I understand that I must either provide documentation of these immunizations or actively decline them. Meningococcal meningitis (Menomune/Menactra) Date: ______/______/______ or sign waver, below. Hepatitis B Dose (date): 1.______/______/______ 2 .______/______/______ Positive Titer Date 3. ______/______/______ or ______/______/______ or sign waver, below. I have been made aware of the potential fatal nature of meningococcal meningitis and choose not to be vaccinated. I have been made aware of the risks associated with hepatitis B and choose not to be vaccinated. ____________________________________________________ Date: ______________ Signature of Student or Parent/Guardian (If student is under 18) IMPORTANT IMMUNIZATION INFORMATION FOR ALL FAU STUDENTS Many extremely valuable vaccines are available to help prevent certain diseases. Preventing any of the following diseases is highly desirable and is best accomplished with vaccinations. Measles, mumps, rubella (MMR), hepatitis B and meningococcal meningitis (Menactra) vaccines are available to prospective students, prior to registration, at Student Health Services (SHS) located at the Boca Raton, Davie and Jupiter campuses. Titers providing serologic evidence of immunity are also available for measles, mumps, rubella and hepatitis B. Charges for immunizations or titers are billed to the student. Call the campus near you: FAU Student Health Services Boca Raton Campus (561) 297-2282 Davie Campus (954) 236-1556 • Jupiter Campus (561) 799-8678 Meningococcal meningitis is a rare bacterial infection of the membranes surrounding the brain and spinal cord. It can cause severe neurological damage, loss of limbs, or death. The vaccine Menactra protects 90% of its recipients against four of the five serotypes of bacteria which cause this form of meningitis. Protection is believed to last for a minimum of eight years. People with a history of latex allergy, Guillain-Barré syndrome or previous serious allergic reaction to Menactra should not receive the vaccine. Pregnant women must consult with their physicians prior to receiving Menactra. Hepatitis B is a serious viral liver disease that can lead to chronic liver disease, liver cancer or, rarely, death. Hepatitis B vaccine is believed to confer lifelong immunity in most cases. People with a history of life-threatening reaction to baker’s yeast or to a previous dose of hepatitis B vaccine should not receive the vaccine. Pregnant women may be vaccinated. Measles is a highly contagious viral infection that can cause ear infection, pneumonia, seizures, brain damage or even death. Pregnant women and people who have ever had a life-threatening reaction to gelatin, neomycin or a previous dose of MMR vaccine should not receive the MMR vaccine. Rubella is a contagious viral infection that causes a rash, mild fever and stiff joints in adults. A pregnant woman who contracts rubella could have a miscarriage or her baby could be born with serious birth defects. Two doses of MMR vaccine can provide long-term, effective protection against these diseases. Anyone who has one of the following should consult with a physician prior to receiving the MMR vaccine: HIV/AIDS or other diseases of the immune system; cancer or is receiving cancer treatment; blood disorders or recent receipt of blood transfusions or blood products. Pregnant women and people who have ever had a life-threatening reaction to gelatin, neomycin or a previous dose of MMR vaccine should not receive the MMR vaccine. GENERAL INFORMATION GENERAL INFORMATION The Student Health Services (SHS) on the Boca Raton campus is staffed by board-certified physicians, advanced registered nurse practitioners, registered nurses, a board-certified dentist, dental hygienists, health and wellness educators and well-trained support staff to serve your healthcare and health education needs. An advanced registered nurse practitioner provides primary healthcare on the Jupiter and Davie campuses. Community healthcare partner (Linda Delo, D.O.) also provides primary care medical services for students. More information about the services provided may be found at www.fau.edu/shs or by calling (561) 297-3512. Your Student Health Fee, part of the tuition you pay each semester, helps to defray the costs of routine visits. However, fee-for-service charges may also be assessed during your visit. These include, but are not limited to: office visits, lab tests, including blood collection (phlebotomy) procedures, medications, treatments, supplies, immunizations, complete physical examinations, women’s and men’s health examinations, dental cleanings/x-rays/procedures, diagnostic tests (e.g., EKG, ultrasounds, etc.) and copies of records. These fees are charged to your FAU student account. OUTSIDE CLINICS, SPECIALISTS AND HOSPITALS Your Student Health Fee does not apply to any care outside of SHS. Referrals to specialists are made as needed by SHS providers. Students are responsible for payment for these outside services. FAU COUNSELING AND PSYCHOLOGICAL SERVICES FAU Counseling and Psychological Services are located on the Boca Raton, Davie and Jupiter campuses and offer psychological, psychiatric, psycho-educational and clinical social work services at no additional cost to registered students. Please call (561) 297-3540 for further information about services offered at the various locations. INSURANCE Students are strongly encouraged to have health insurance coverage. If you are not covered by your family health insurance plan and you want coverage, FAU sponsors an injury and sickness policy for students. This coverage is optional for domestic students, but international students must meet mandatory insurance requirements prior to registration and should call Student Health Services at (561) 297-1116 for further information. Contact Insurance for Students at 1 (800) 356-1235 for policy details or visit www.fau.edu/shs. CONFIDENTIALITY OF RECORDS All medical records are strictly confidential and cannot be released without the patient’s written consent. Parents or legal guardians of students under 18 have the legal right to review medical records of their children except for issues relating to birth control or sexually transmitted diseases. In most cases, a signed authorization for disclosure of protected health information in a medical record expires in 90 days. FAU Student Health Services Boca Raton Campus (561) 297-2282 • Fax (561) 297-2769 Davie Campus (954) 236-1556 • Jupiter Campus (561) 799-8678 120523