Student Health Information - Missouri Valley College

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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.
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Student Health Information - Missouri Valley College

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