Student Health Information - Missouri Valley College

Missouri Valley CollegeStudent Health ServicesDiane Weinreich, APRN, FNP500 E CollegeMarshall MO 65340Phone: (660) 831-4012Fax: (660) 831-4039E-mail: weinreichd@moval.edu2012-2013Welcome to Missouri Valley College.Vaccine preventable illness continues to occur on campuses across our nation. To help ensure the health andwell-being of our students, Missouri Valley College follows the recommendations set by the American CollegeHealth Association for immunization practice.It is required that all students living on campus submit a copy of their immunization record. If it isalready on file at MVC, only updated immunizations need to be submitted (if applicable); including yearlymeningococcal waiver (if applicable) and yearly Tuberculosis Screening Form.Please refer to http://www.acha.org/Topics/vaccine.cfm for the Recommendations for InstitutionalPrematriculation Immunizations. While these are recommendations set forth by the American College HealthAssociation, the following immunizations are mandated by Missouri state law and/or Missouri Valley College:Measles, Mumps, Rubella (MMR) (2 doses)Tetanus, Diphtheria, Pertussis (with Td booster dose every 10 years)Meningococcal Tetravalent (Meningitis vaccination) or Signed Meningitis Vaccination Waiver FormFor any student living on campus who does not wish to receive the meningitis vaccination, the enclosed waivermust be signed by the student or legal guardian if student is under the age of 18 stating you understand the risksof meningitis disease which can include: hearing loss, learning disability, brain damage, & death. This waiverneeds to be signed yearly if the choice to not immunize is selected.The following screening form is required for all students living on campus to be filled out yearly:Tuberculosis Screening FormIf you have any questions, please do not hesitate to contact me at the above e-mail, phone number, or fax.Thank you for your cooperation,Diane Weinreich, APRN, FNP

Missouri Valley CollegeStudent Health ServicesDiane Weinreich, APRN, FNP500 E CollegeMarshall MO 65340Phone: (660) 831-4012Fax: (660) 831-4039E-mail: weinreichd@moval.edu2012-2013Meningitis Vaccination Waiver FormNOTE: For any student living on campus who does not wish to receive this vaccination,the waiver below must be signed yearly by the student or legal guardian if student isunder the age of 18 stating you understand the risks of meningitis disease which caninclude, but not limited to: hearing loss, learning disability, brain damage, & death.Name_______________________________________Signature____________________________________Date________________________

Tuberculosis (TB) Screening Form2012‐2013Name:_________________________________________________To be filled out by Missouri Valley College Student:Have you ever had a positive TB skin test? Yes NoHave you ever had close contact with anyone who was sick with TB? Yes NoWere you born in one of the countries listed below and arrived in the U.S.Within the past 5 years? (if so, please CIRCLE the country) Yes NoHave you ever traveled* to/in one or more of the countries listed below?(if yes, please CHECK the country/ies) Yes NoHave you ever been vaccinated with BCG? Yes No*The significance of the travel exposure should be discussed with a health care provider and evaluatedAfghanistanAlgeriaAngolaArgentinaArmeniaAzerbaijanBahrainBangladeshBelarusBelizeBeninBhutanBoliviaBosnia/HerzegovinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCentral AfricanRepublicChadChinaColumbiaComorosCongoCook IslandsCote d’IvoireCroatiaDemocraticPeople’s Rep. ofKoreaDemocratic Rep.Of the CongoDjiboutiDominican Rep.EcuadorEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFrench PolynesiaGabonGambiaGeorgiaGhanaGuamGuatemalaGuineaGuinea‐BissauGuyanaHaitiHondurasIndiaIndonesiaIraqJapanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People’sDemocratic Rep.LatviaLesothoLiberiaLibyan ArabJamahiriyaLithuaniaMadagascarMalawiMalaysiaMaldivesMaliMarshall IslandsMauritaniaMauritiusMicronesiaMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNepalNicaraguaNigerNigeriaPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRepublic of KoreaRepublic of MoldovaRomaniaRussian FederationRwandaSaint Vincent &GrenadinesSao Tome & PrincipeSenegalSerbiaSeychellesSierra LeoneSingaporeSolomon IslandsSomaliaSouth AfricaSri LankaSudanSurinameSwazilandSyrian Arab RepublicTajikistanThailandThe former YugoslavRepublic ofMacedoniaTimor‐LesteTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Republic ofTanzaniaUruguayUzbekistanVanuatuVenezuelaViet NamYemenZambiaZimbabweIf the answer is YES to any of the above questions, Missouri Valley College requires that a health care providercompleted a tuberculosis risk assessment (to be completed within 6 months prior to the start of classes)If the answer to ALL of the above questions is NO, no further testing or further action is required.

Tuberculosis Risk Assessment 1Student’s Name_____________________________Persons with any of the following are candidates for either Mantoux Tuberculin Skin test (TST) or InterferonGamma Release Assay (IGRA), unless a previous positive test has been documented:To be filled out by health care provider:Recent close contact with someone with infections TB disease YES NOForeign‐born from (or travel* to/in) a high‐prevalence area (e.g., Africa, Asia,Eastern Europe, or Central or South America) YES NOFibrotic changes on a prior chest x‐ray suggesting inactive or past TB disease YES NOHIV/AIDS YES NOOrgan transplant recipient YES NOHistory of illicit drug use YES NOResident, employee, or volunteer in a high‐risk of progressing to TB disease ifInfected [e.g., diabetes mellitus, silicosis, head, neck, or lung cancer, hematologic orReticuloendothelial disease such as Hodgkin’s disease or leukemia , end stage renalDisease, intestinal bypass or gastrectomy, chronic malabsorption syndrome, low bodyWeight (ie., 10% or more below ideal for the given population)] YES NO*the significance of the travel exposure should be discussed with a health care provider and evaluated.1. Does the student have signs or symptoms of active TB disease? YES______ NO_____If NO, proceed to 2 or 3. If YES, proceed with additional evaluation to exclude active TB disease including TST,CXR and sputum evaluation as indicated.2. TST(TST results should be recorded as actual millimeters (mm) of induration, transverse diameter; if noinduration, write “0”. The TST interpretation should be based on mm of induration as well as risk factors.)**Date Given: ___/___/___Results:______mm of indurationDate Read: ___/___/___**Interpretation: Positive_____Negative_____Date Given: ___/___/___Results:______mm of indurationDate Read: ___/___/___**Interpretation: Positive_____Negative_____

Tuberculosis Risk Assessment 2Student’s Name_____________________________3. Interferon Gamma Release Assay (IGRA)Date Obtained:___/___/___ (specify method) QFT‐G QFT‐GIT T‐Spot Other__________Result: negative_____ positive_____ indeterminate_____ borderline_____ (T‐Spot only)Date Obtained:___/___/___ (specify method) QFT‐G QFT‐GIT T‐Spot Other__________Result: negative_____ positive_____ indeterminate_____ borderline_____ (T‐Spot only)4. Chest X‐Ray (Requiredif TST or IGRA is positive)Date of Chest X‐Ray:___/___/___ Result: normal_____ abnormal_____** Interpretation guidelines>5mm is positive:1. Recent close contacts of an individual with infectious TB2. Persons with fibrotic changes on a prior chest x‐ray consistent with past TB disease3. Organ transplant recipients4. Immunosuppressed persons: taking >15mg/day of prednisone for >1 month; taking TNF‐α antagonist5. Persons with HIV/AIDS>10mm is positive:1. Persons born in a high prevalence country or who resided in one of a significant* amount of time2. History of illicit drug use3. Mycobacteriology laboratory personnel4. History of resident, worker, or volunteer in a high‐risk congregate settings5. Persons with the following clinical conditions: silicosis, diabetes mellitus, chronic renal failure, leukemias and lymphomas,head, neck or lung cancer, low body weight (10% below ideal), gastrectomy or intestinal bypass, chronic malabsorption syndromes.>15mm is positive:1. Persons with no known risk factors for TB disease**The significance of the exposure should be discussed with a health care provider and evaluated.If the chest x-ray and medical exam are normal, it is the policy of Missouri Valley College that treatment for latent TBinfection should be initiated before coming on campus.This policy is recommended by the American College Health Association.