RETURN COMPLETED FORMS (PARTS A, B and C)
DUE NO LATER THAN:
JULY 15, 2015
Obtaining proof of immunization may be
a time-consuming process, so start now!
Ringling College of Art and Design requires all new students to show proof of the following immunizations prior
to attending classes at Ringling College:
1.
2 MMRs (
or
two Measles (Rubeola) vaccines with one dose of Rubella are acceptable)
2.
MCV4 (Menactra/Menveo) vaccine for resident students or signed waiver for commuter
students.
3.
Hepatitis B vaccines or signed waiver
4.
Tuberculosis screening is required for all International Students. Additionally, all
students who have lived in or traveled to “high incidence” countries should be screened.
(A
list of “high incidence” areas is available at www://who.int/globalatlas/dataQuery/default.asp).
Ringling College of Art and Design will accept official State Immunization Forms issued by local health
departments and physicians’ offices, in conjunction with
obtaining a doctor’s signature
on Parts A & B.
An
exception to these policies may be granted in the event of valid medical contraindications or for religious
reasons. In the event of outbreak, exempted students will be excluded from campus activities, until such time
as specified by the Sarasota County Public Health Department.
Help with locating your vaccination records can be found at:
http://www.cdc.gov/vaccines/adults/vaccination-records.html
Please include STUDENT NAME on every page.
Return Parts A, B and C of this Packet by
July 15, 2015
to:
Ringling College of Art and Design STUDENT HEALTH INFORMATION FORMS
2700 N. Tamiami Trail, Sarasota, FL 34234
Or by fax: 941-359-4854, or scan and email to: [email protected]
Instructions for Part A - RCAD Mandatory Immunization Health History Form
Basic Instructions: DO NOT WAIT! Late, incomplete or inaccurate information may delay registration.
☐ Include the Student’s Name and Birth Date on all correspondence. Print all student information legibly.☐ Have a licensed medical provider fill out and sign the medical areas of Form A or attach an official Certification of immunization from a State Health Department. Students who have answered “Yes” to any questions on Form B must also obtain a provider’s signature at the bottom of the TB Risk Assessment Form.
☐ MINORS (students under 18): A parent/guardian signature must be included for waivers and medical treatment.
☐ KEEP A COPY FOR YOUR RECORDS. Should anything be amiss, you can easily refer to what was sent to us.
☐ Mail or fax Parts A, B & C (and lab reports as needed) no later than the established deadline to:
Ringling College of Art and Design, Student Health Information, 2700 N. Tamiami Trail, Sarasota, FL 34234, Fax: 941-359-4854. Or scan and email to: [email protected]
Part A - Section A: Information about Required Immunizations
1. MMR / MEASLES, MUMPS, RUBELLA VACCINE – Required for EVERYONE born after Dec. 31, 1956. This combination vaccine is given because it protects from Measles, Mumps and Rubella. Two doses are required for entry into Ringling College of Art and Design. One must have been received on or after the first birthday AND in 1971 or later. The second dose must have been received at least 30 days after the first dose AND in 1990 or later.
OR: Provide lab evidence of immunity by doing a blood test to check for antibodies for Measles, Mumps and Rubella. If you do a blood test, you need to provide the results on a lab form that should be faxed or mailed with the completed Mandatory Immunization Health History Form. ***NOTE: All titers must include a lab report.***
2. HEPATITIS B VACCINE – Based on the Center for Disease Control’s recommendations, students are encouraged to receive this vaccine series. Students wishing to decline this vaccine must discuss the disease and symptoms caused by the Hepatitis B virus with their physician, then check and sign where indicated on the Mandatory Immunization Health History Form. Signing the waiver indicates you understand the possible risk in not receiving this vaccine. If you are under the age of 18 and wish to decline this vaccine, a parent must sign for you.
3. MCV4 (MENACTRA/MENVEO) / MENINGOCOCCAL MENINGITIS VACCINE – Based on recommendations from the CDC and the American College Health Association (ACHA), Ringling College of Art and Design requires that all students living in Ringling campus housing be vaccinated against Meningitis. As such, Ringling College requires of all new residential
students a vaccination date after 8/2010 or that the most recent dose was administered after age 16. Commuter students wishing to decline this vaccine must discuss the benefits of the Meningococcal Meningitis vaccination with their physician, then check and sign where indicated on the Mandatory Immunization Health History Form. Signing the waiver indicates you
understand the possible risk in not receiving this vaccine. If you are under 18 and wish to decline this vaccine, a parent must sign for you.
4. Tuberculosis Screening: Required for International Students – A Tuberculosis Skin Test by PPD or Mantoux (within the last year) is required for international students. NOTE: If both PPD and MMR are given, they must be given on the same day for the PPD to be accurate or given 30 days apart. PPDs must be read between 48-72 hours of administration. The result must be listed in “mm” and indicated whether negative or positive in the space indicated. If the PPD is positive, submit a copy of the chest X-ray report done on or after PPD placement. If you do the blood test—Interferon-based Assay (QFT or Tspot)—submit a copy of the laboratory report. If the PPD is positive or the Interferon-based Assay is positive, submit a copy of the chest X-ray report.
Part A - Section B: Information about Recommended Immunizations for Good Health
• Td (Tetanus/Diphtheria) or/and Tdap (Tetanus/Diphtheria/Pertussis) – Booster shot within last 10 years. Space is provided to record this information.
• Varicella (Chickenpox) – Provide proof of two doses of Varivax. OR: Provide results of a blood test on a lab form verifying immunity to Chickenpox/Varicella. ***NOTE: All titers must include a lab report.***
• Hepatitis A, HPV, Polio, Other – In the boxes provided in this section you may also list any additional vaccines that were administered. These are not required.
Part A - Mandatory Immunization Health History Form
Name__________________________________Date of Birth____________Age____
Section A: Required Immunizations
***NOTE: ALL TITERS MUST INCLUDE LAB REPORT***Month/Day/Year Month/Day/Year Month/Day/Year TITER DATE & RESULT 1. MMR (Measles, Mumps, Rubella)
(2 doses on or after first birthday)
DO NOT WRITE HERE
2. Hepatitis B OR sign waiver below
3. MCV4 (Menactra/Menveo) OR sign waiver below You may not waive if living on campus.
DO NOT WRITE HERE DO NOT WRITE HERE
£
I have discussed the Hepatitis B vaccine with my medical provider and decline receipt of this vaccine.£
I will not be living on campus. I have discussed the MCV4 with my medical provider and decline receipt of this vaccine.
Signature Of Student Date OR Signature Of Parent/Guardian If Student Under 18 Relationship To Student Date
4. Tuberculosis Screening: Required for International Students
TB Skin Test by PPD (Mantoux) Date Placed Date Read MM
Neg Pos
OR Interferon-based Assay (QFT or Tspot) Date Result ***Submit copy of lab report*** Chest X-ray (if positive PPD or lab) Date Result ***Submit copy of chest X-ray report***
Section B: Recommended Immunizations for Good Health
***NOTE: ALL TITERS MUST INCLUDE LAB REPORT***Month/Day/Year Month/Day/Year Month/Day/Year TITER DATE & RESULT
Td (Tetanus/Diphtheria)
DO NOT WRITE HERE / DO NOT WRITE HERE DO NOT WRITE HERE
AND/OR Tdap (Tetanus/Diphtheria/Pertussis)
DO NOT WRITE HERE / DO NOT WRITE HERE DO NOT WRITE HERE
Varicella (Chickenpox)
DO NOT WRITE HERE
Hepatitis A
HPV (Gardasil or Cervarix)
DO NOT WRITE HERE
Polio (last date)
DO NOT WRITE HERE / DO NOT WRITE HERE DO NOT WRITE HERE
Other:
An official stamp from a medical health provider w/ authorized signature required below or an official State Immunization Form attached to this page.
Official Office Stamp Here Physician Or Authorized Signature Date
MEDICAL TREATMENT CONSENT (For Student Under 18): I hereby authorize the Student Center and Peterson Counseling Center to employ diagnostic
procedures and to render any treatment or medical, surgical, psychological or psychiatric care deemed necessary to the health and well-being of my child. I grant permission for the transfer of my child to an accredited hospital or other health care facility if deemed necessary by the medical or mental health provider.
Signature Of Parent/Guardian Relationship To Student Date
☐I also grant permission for Sarasota Memorial Hospital, the Student Health Center, or its designees to administer required vaccinations or optional vaccinations (e.g. annual influenza) at the request of my student. Parent/Guardian please check box and initial here:_________________________________
IMPORTANT! KEEP A COPY OF THIS PAGE AND ALL LAB REPORTS FOR YOUR RECORDS. M a i l t h i s p a g e ( a n d l a b r e p o r t s ) b y J a n u a r y 5 , 2 0 1 5 t o : R i n g l i n g C o l l e g e o f A r t a n d D e s i g n , S t u d e n t H e a l t h I n f o r m a t i o n F o r m s , 2 7 0 0 N . T a m i a m i T r . ,
Student Name Date of Birth Month: Day: Year: Age:
PART B – TUBERCULOSIS RISK WORKSHEET
The countries below have a high incidence of TB. Were you born in one of these countries or do you take
frequent or prolonged trips (greater than one month) to one of these countries? YES NO If yes, please circle the country from the list below. Refer to www.cdc.gov for updated list.
Have you ever:
Had close contact with persons known or suspected to have active TB disease? YES NO Been a resident and/or employee of a high-risk congregate setting (e.g. correctional facilities,
long term care facilities, homeless shelters? YES NO
Been a volunteer or health care worker who served clients who are at increased risk for active TB? YES NO Been a member of the following groups that may have an increased incidence of latent or active TB:
medically underserved, low-income, or abusing drugs or alcohol? YES NO
Currently experience: Coughing lasting 3+ weeks not related to other condition (e.g. asthma, allergies)? YES NO
Coughing up blood (hemoptysis)? YES NO
Weight loss unrelated to change in diet or exercise? YES NO
Night sweats that occur on a regular basis? YES NO
Fever unrelated to another known condition? YES NO
Students who answered “Yes” to any questions on this page must review and discuss their risk to Tuberculosis with a health provider. All international students must complete #4 on Part B of the Mandatory Immunization Health History Form.
Student Signature ______________________________________________________ Date: ________________ Health Provider who has Reviewed/Discussed TB risk:
Provider Name: _______________________________ Recommend TB Testing: YES NO
Signature: __________________________________________________________ Date: ________________ Afghanistan Algeria Angola Argentina Armenia Azerbaijan Bahrain Bangladesh Belarus Belize Benin Bhutan Bolivia
Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde
Central African Republic Chad China Colombia Comoros Congo Côte d'Ivoire Croatia Democratic People's Republic of Korea Dem. Rep. of the Congo Djibouti Dominican Republic Ecuador El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Gabon Gambia Georgia Ghana Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iraq Japan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lesotho Liberia Libyan Arab Jamahiriya Lithuania Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Micronesia
(Federated States of) Mongolia Morocco Mozambique Myanmar Namibia Nepal Nicaragua Niger Nigeria Pakistan Palau Panama
Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda
Saint Vincent and the Grenadines
Sao Tome and Principe Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Sudan Suriname Swaziland
Syrian Arab Republic Tajikistan
Thailand
The former Yugoslav Republic of Macedonia Timor-Leste Togo Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe
Student Name Date of Birth Month: Day: Year: Age:
PART C - MEDICAL POLICIES & HEALTH INSURANCE REQUIREMENT
I. Ringling College of Art and Design provides on-campus health services through an arrangement with the Sarasota Memorial Health Care System to diagnose and treat most common illnesses and conditions. Most services that cannot be provided directly on-site at the campus clinic can be coordinated within Sarasota Memorial’s comprehensive network of services. (A complete description of the services provided to enrolled students is available at http://health.ringling.edu). If you have a medical history or other condition you would like to discuss with our medical staff, please call 941-309-4000 or visit us during the first week of classes for an initial consultation with our on-campus Physician’s Assistant. Any evidence in the future that this Health Form has been falsified or incomplete may be grounds for immediate suspension from the College. Ringling College shall reserve the right to reject or overturn acceptance for admission to the College if information on this form would indicate need for such action.
II. Attendance at counseling/medical appointments either on or off campus, or other documentation of a medical condition provided to the health center, is insufficient to grant excused class absences or any form of accommodations. For questions about course work or attendance policies, which are often very strict, it is the student’s responsibility to communicate directly with faculty, as well as consulting the office of disability services and the assigned academic advisor to meet required standards in a timely manner. Emergency medical withdrawals may be granted only in emergency situations and require documentation from appropriate non-family licensed providers documenting a diagnosis and subsequent emergency situation which substantially interfered with the student’s ability to function academically for an extended period of time. Be sure to review the student handbook and academic calendar for more details.
III. We highly recommend students notify the Coordinator of Residence Life, roommate, faculty and any staff they wish to be aware of any conditions that could present a risk to themselves or others or require regular visits to a physician. We recommend students self disclose conditions such as: Allergies to Medications, Arthritis/Rheumatism, Diabetes, Digestive Problems, Epilepsy, Fainting Spells, Heart Trouble, Hypoglycemia, Food Allergies, etc.
IV. Health Insurance Requirement - Ringling College of Art and Design requires all students to have health insurance. For students who have comparable insurance through a home provider we offer a simple online waiver. Students with their own plan must complete the waiver form online at www.ringling.edu/insurance by the deadline of July 15, 2015. Once the waiver has been approved, the charge will be removed from the student’s account and a new statement will be sent from the Bursar’s Office. Students who wish to enroll in the plan through the College must complete an enrollment form at www.ringling.edu/insurance.
Detailed information about the Student Health Insurance Plan can be found online at www.ringling.edu/insurance. The plan offers all essential medical benefits with a small co-pay and deductible, provides access to national PPO Network Providers, and carries no pre-existing condition exclusions. Preventative services are paid at 100% with no deductible or coinsurance when provided at the Student Health Center or with an in-network provider. If I elect to waive participation in the Student Health Insurance Plan, I acknowledge that I am legally responsible for any and all medical expenses incurred for the policy period at Ringling College. Your signature below is an
acknowledgement of understanding the process and information provided here, and does not affect your coverage by any plan. Only information provided by the insurance company directly should be considered in making determinations about coverage or medical care and no other conversation, document, or exchange with a college representative should be taken as an indication of terms or effective dates of coverage. I further understand and acknowledge that if I do not waive coverage online by July 15, 2015, I (or my student) will automatically be insured under this plan and the premium cost will remain on my student account. While a student may be allowed to continue to use the duration of an existing policy if premiums have been paid in good standing prior to a leave, they may not enroll or re-enroll while on leave or after graduation. Students may not withdraw from the full-academic year policy following the established deadline, generally 30 days after the first day of the academic year.
Please contact the insurance company directly for questions about coverage, claims and authorization at www.ringling.edu/insurance OR CALL MS DARYL HALL, HSA Consulting Inc. at : 1-888-978-8355 OR email [email protected].
I certify that I have read the College’s policy statements above. I understand that failure to complete this form in full and to return it by the deadline may result in the College preventing me from registering for classes or assuming occupancy in the residence halls. I understand I am also responsible for having a physician review PARTS A & B of the health form, before returning it to the College by the deadline. Student’s Signature_______________________Student’s Name (Print)_______________________________Date____________ Parent’s Signature________________________Parent’s Name_(Print)_______________________________Date____________
ADDITIONAL INFORMATION (OPTIONAL) – RETAIN THIS FORM FOR YOUR USE
Please contact the following offices with additional information you wish to share.
I. DISABILITY SERVICES 941.359.7627 <[email protected]>
If you have a disability of any kind—medical, mobility, hearing, learning, attention, psychological or other—please contact Virginia DeMers, Director of the Academic Resource Center to discuss reasonable accommodation options. Students with mobility issues will be need to address those ahead of time; the College does not provide transportation services on campus. College classes and activities are held across the entire campus. The Academic Resource Center arranges classroom and other accommodations for students whose disabilities limit their access to Ringling programs and curricula. In addition, the Academic Resource Center provides many support services that are available to all students.
II. SPECIAL DIETARY INFORMATION 941.355.8064 <[email protected]>
If you wish to discuss special health-related dietary concerns with the Director of Food Services prior to attending Ringling College, please contact Ron Haynes. A special diet that meets doctor’s orders can be created. General meal plan option questions can be directed to Residence Life.
III. MENTAL HEALTH INFORMATION 941.893.2855 <[email protected]>
If you have ever undergone treatment for any emotional or mental condition or been under the care or treatment of a clinical social worker, psychologist, psychiatrist or other mental health professional, you may wish to speak with a counselor. The Peterson Counseling Center provides free and confidential psychotherapy. Our counselors can also make referrals to off-campus providers, speak with home providers and parents with proper releases of information. If you wish to share
information with a home provider or a family member please complete and sign the Peterson Counseling Center Release of Information Form found at http://health.ringling.edu and include it with your packet.
IV. OTHER KEY CONTACTS
To report special campus living needs, please email or call Residence Life:941.309.1963 <[email protected]> Commuter Students may call The Office of Student Life at 941.359.7505 for any commuter-related concerns. Student Health Center Medical Services:
941.309.4000 or <[email protected]> or fax 941.351.4018 http://health.ringling.edu
V. HEALTH INSURANCE 888-978-8355 [email protected]
To speak with a Customer Service Representative about coverage, claims, enrollment or the waiver process call: Daryl Hall, HSA Consulting Inc. – 1-888-978-8355, email [email protected] or visit www.ringling.edu/insurance or https://app.hsac.com/ringling.
For general questions about this form, you may contact [email protected] 941.893-2855.
