Congratulations and welcome to the University of Massachusetts Worcester!

The following is a checklist for you to use as a guide as you complete the Student Health requirements.

All sections of the Health Clearance must be completed by your provider prior to entering (if you begin classes in July or September , the form is due no later than 2 weeks prior to the start of class. Please complete this ASAP. If you do not meet health clearance requirements listed below you will be held from class and/or lab experiences until it is complete. If you are missing any information an email will be sent to the e-mail address you list on the form.

The Health Clearance forms may also be downloaded for your convenience from the Student Health Services (SHS) website www.umassmed.edu/studenthealth. Please check that your provider has filled in the information clearly and completely on the health clearance form and has provided the necessary supporting documentation.

Please note: A copy of the lab reports for all titers must be included with your forms. Also, any information provided in another language must be translated into ENGLISH.

STUDENT HEALTH CLEARANCE CHEKLIST

1. Physical exam: Within the past year dated and signed by your provider. ⁯

2. MMR (Measles, Mumps, Rubella): MMR vaccine dates (2 doses) or positive titers.

(Please Note: If measles, mumps or rubella titers are negative you must provide dates of 2 MMRs (month/ day/year)

MMR #1 ⁯ MMR #2 ⁯ or Measles titer ⁯ Mumps titer ⁯ Rubella titer ⁯

3. Hepatitis B: Dates of immunizations (3 doses) or Hepatitis B antibody titer.

** (Please Note: If you do not have a positive Hepatitis B antibody titer you must provide Hep B series dates.

Hep B #1 ⁯ Hep B # 2 ⁯ Hep B #3 ⁯ or Hep B Surface Antibody titer ⁯

4. Varicella(Chicken pox): Dates of Immunization (2 doses) or positive Varicella titer.

Varicella #1 ⁯ Varicella # 2 ⁯ or positive Varicella titer ⁯ or Date of Disease ⁯

5. Tetanus: A one-time Tdap (Pertussis component included) is required. Also include the date of your last Td. ⁯

6. 2-Step Tuberculosis Skin Test (TST): 2-step TST is required within 3 months before the start of school or Quantiferon

Gold serology orT-Spot results.

TST result #1 ⁯ TST result #2 ⁯ or Quantiferon Gold / Tspot result ⁯

Please refer to Health Clearance Form for specific TST requirements. 2-Step TST Information sheet also attached.

**NOTE: If you have a history of a positive TST, date of positive result and documentation of treatment, if any, must be provided. In addition, a copy of a chest x-ray report taken after the positive TST must be attached. Also fill out the attached Symptom review, sign and date within 3 months prior to the start of school.

⁯ Chest X-ray report ⁯ Treatment	⁯ Symptom Review

Remember you must submit the completed Health Clearance Form with proper documentation and be cleared by Student Health before you can attend classes or receive a paycheck.

STUDENT HEALTH CLEARANCE FORM

UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL

55 Lake Avenue North

Worcester, MA 01655

Phone (508)334-8464

Fax (774)443-2350

studenthealth@umassmemorial.org

NAME:	________________________________________________________________ M_____ F______

Last First Middle

ADDRESS:	________________________________________________________________________________

Street City State Zip

TELEPHONE:	________________________________	EMAIL: _________________________________________

DOB:	_______________________________	ENTRANCE YEAR: _______________________________

SCHOOL: Graduate School of Biomedical Sciences

The following information MUST be completed by the applicant’s healthcare provider, BEFORE he/she can attend class.

PROVIDER COMPLETES

Medical History: Please list all chronic medical conditions:	⁯ Check here if this patient currently has, or has a history of Blood Borne Pathogen Infection (i.e. HIV, Hepatitis B, or Hepatitis C). Please provide details in medical history.

Surgical History:

Allergies: (medications, foods, latex, environmental)

Current Medications:

**If you require close follow-up for any medical or mental health issues, please contact us ahead of time to ensure that you receive continuity of care.

Medical Care – 508-334-8464 Mental Health Care – 508-856-3220

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Student Last Name ________________________________ First Name _________________________ DOB _________

1. Date of Last Physical: (MUST be within 1 year of school admission) ________________________________________

Month/Day/Year

2. MEASLES, MUMPS, RUBELLA (MMR): Provide MMR immunizations (2 doses) or positive titer results as proof of immunity.

A copy of the titer reports MUST be attached. (Please note: If any titer is negative, documentation of 2 doses of MMR are required.)

MMR #1 _________________ (MM/DD/YYYY)

MMR #2 _________________(MM/DD/YYYY)

Measles titer:	_____________	(MM/DD/YYYY)

Rubella titer:	_____________ (MM/DD/YYYY) Lab reports MUST be attached.

Mumps titer:	_____________ (MM/DD/YYYY)

3. TETANUS DIPTHERIA (Td/Tdap): A one- time Tdap 2006 or after is required. Include last Td date also.

Tdap _______________________ (MM/DD/YYYY) Td ____________________ (MM/ DD/YY)

4. HEPATITIS B: Provide Hepatitis B immunization dates (3 doses) or a positive Hepatitis B surface antibody titer. A copy of the titer report MUST be attached.

Hep B #1 __________________ (MM/DD/YYYY) Hep B #4 ______________________ (MM/DD/YYYY)

Hep B #2 __________________ (MM/DD/YYYY)	Hep B #5 ______________________ (MM/DD/YYYY)

Hep B #3 __________________ (MM/DD/YYYY) Hep B #6 ______________________ (MM/DD/YYYY)

HBSab Titer: _________________ (MM/DD/YYYY) Result: Positive ⁭ Negative ⁭

5. VARICELLA (Chickenpox): Varicella Immunization (2 doses) or a positive Varicella Titer (lab report MUST be attached).

Varicella #1: ________________ (MM/DD/YYYY)

Varicella #2: ________________ (MM/DD/YYYY)

Varicella Titer: _______________ (MM/DD/YYYY) Do you have a history of Varicella? Yes ⁭ No ⁭ If Yes, Date: ____________

6. 2- STEP TUBERCULIN SKIN TEST (TST): 2 step TST or Quanterferon Gold Test or equivalent serology result.

If you have no history of a 2-step TST, you will need to complete two TST’s (Ideally1-4 weeks apart), within 3 months prior to the start of school.

If you have had a 2-step in the past and have maintained annual TST testing since your 2 step please provide this documentation – Only one TST is required to be completed within 3 months prior to the start of school.

If you have had a previous TST within the current year only one TST is required to be completed within 3 months prior to the start of school. Please be sure to provide documentation of both.

TST #1 ______________(MM/DD/YYYY) Result: NEG ______ POS ______ mm ________ Quantiferon Gold/T-Spot result pos / neg

TST #2 ______________(MM/DD/YYYY) Result: NEG ______ POS ______ mm ________ (Attach lab report)

If you have had a positive TST, a copy of a chest x-ray report after the positive result date must be submitted, and any subsequent treatment (i.e. INH)** History of BCG Vaccine does not exempt you from completing the 2-stepTST. ** Also please fill out sign and date the attached Symptom Review questions within 3 months prior to the start of school.

POSITIVE TEST RESULT: DATE: ______________ MM of induration _________ TREATMENT: YES ⁭ NO ⁭

IF YES, DATES OF TREATMENT: _____________________________HISTORY OF BCG VACCINE DATE: __________________

DATE OF CHEST X-RAY ______________ Copy of the report MUST be attached.

SYMPTOM REVIEW\ _________________ (See back of attached TST form)

EXAMINER SIGNATURE: ___________________________________ DATE: ____________________________________________

MD/ NP/ PA

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