- Health Form Checklist
This checklist is being provided to assist you in completion of your Health Center packet. Before submitting your form, please review the items below for completion:
______1. All required sections of the form are complete and in ENGLISH or with English translation.
______2. Proof of immunization/immunity is attached. You must provide photo copies of health documents. Acceptable documentation includes: travel documents, official school record, official health department record, medical record from health care provider’s office. Alternatively, you may have your health care provider complete the immunization section of the Health History Form and sign it. Records in a language other than English require translation into English prior to submission to the Health Center. If you are missing documentation for the required vaccinations, you may repeat the immunization or demonstrate proof of immunity with a titer (a blood test-MMR panel).
______3. I have completed and signed the Tuberculosis questionnaire located in the Health Form.
______4. If I am from or if I have visited any of the countries listed in the Health Form I must complete one of the following:
_____ I have documentation of a negative IGRA blood test for TB, if test is positive I must provide a negative chest x-ray.
OR
_____ I have documentation of a NEGATIVE CHEST XRAY, demonstrating that I am free from active TB.
OR
_____ I will obtain a tuberculin skin test upon arrival in the United States, if test is positive I must provide a negative chest x-ray.
______5. If I am an International student and not from or have not visited any of the countries listed in the Health Form a health care provider has completed and signed the TB Risk Assessment located in the Health Form.
These reports MUST be in ENGLISH and certified by a physician. Immunization information and TB test/x-ray information must be official documents and include a health care provider’s signature.
Test
Where/When it can be done
Notes
TB (PPD) Skin Test
ONLY in the U.S. Testing can be obtained at the following locations:
-The Valparaiso University Student Health Center (Monday –Friday when undergraduate classes are in session)
-The Porter County Health Department (Monday-Friday)
-The Student Health Center ONLY accepts cash, checks, or Crusader Cash. The Health Center does not accept credit or debit cards. Appointment is required.
-Appointments are required at the Porter County Health Department.
Interferon Gamma Release Assay (IGRA)
QFT-G or QFT-GIT
Native country or U.S.
Chest X-Ray
Native country or U.S.
(Required if skin test or IGRA is positive)
* A negative chest x-ray is acceptable proof of TB status in lieu of PPD or IGRA testing
______6. I have read the enclosed information on the risks of meningococcal disease and Human Papilloma Virus and the availability and effectiveness of vaccination
______7. I have signed, or if under the age of 18 my parent/guardian has signed the Health History form at the bottom of page 1.
______8. I am a student ATHLETE. I have completed the Pre-Participation Questionnaire and had a physical exam. The physical exam record is complete and signed by my health care provider.
NOTE: A physical exam is recommended for students who plan to participate in on-campus activities, travel, or study abroad, BUT IS NOT REQUIRED.
Thank You for your attention to these details. If you have any questions, don’t hesitate to contact us at 219-464-5060 or by email at Health.Center@valpo.edu