inoming students health forms due y august 1 · varsity team athletics health services staff will...
TRANSCRIPT
CONGRATULATIONS ON YOUR ACCEPTANCE TO SKIDMORE COLLEGE!
The staff of Health Services is pleased you will be joining us. We look forward to helping with
any health concerns you may have while attending Skidmore.
INCOMING STUDENTS HEALTH FORMS DUE BY
New York State law and Skidmore College policyrequire fully completed health and immunizationrecords be filed prior to:
class attendance
Summer Academic Institute (forms due June 1)
London Program
pre-orientation programs
varsity team athletics
Health Services staff will notify you by phone or Skidmore email regarding any problems
Students should check the online health portal to determine if requirements are complete/
incomplete
AUGUST 1
www.skidmore.edu/health-services
https://www.skidmore.edu/health-services/forms/index.php (forms for incoming students)
Phone: (518) 580-5550
Fax: (518) 580-5556
Location: Jonsson Tower, 1st floor
HEALTH SERVICES INFORMATION
General medical care provided for all students
No fees for office visits
No fees for limited quantities of common over-the-counter medications
Urgent Care at Wilton Medical Arts and Saratoga Hospital are both located 5 minutes fromcampus
ADDITIONAL MEDICAL INFORMATION
Feel free to contact Health Services with any questions or concerns.
We wish you a happy and healthy learning experience!
HEALTH REQUIREMENTS CHECKLIST— Forms Deadline
All students must comply with New York State and Skidmore College requirements to register and attend classes, and to move in to campus housing.
HEALTHCARE PROVIDER COMPLETES FORMS (Printout from Healthcare Provider is acceptable)
Physical Exam performed after August 1, 2018Immunization RecordTuberculosis Screening/Testing
STUDENTS WAIVE OR ENROLL IN HEALTH INSURANCE BY AUGUST 1
Visit Bursar website for plan information and to waive or enroll
Visit Health Services website or page 3 of this document for additional information
STUDENTS RETURN THE FOLLOWING BY AUGUST 1
Physical Exam
Immunization Record
Tuberculosis Status
Front/back copy of insurance card
RETURN VIA:
Fax 518-580-5556Email [email protected] (save all paperwork as one document—pdf format preferred)
Mail to: Skidmore College Health Services
815 North Broadway Saratoga Springs, NY 12866
STUDENTS REGISTER FOR ONLINE HEALTH PORTAL
Register & login to the online Student Health Portal at https://skidmore.studenthealthportal.com
Instructions can be found on page 4 of this document or https://www.skidmore.edu/health-services/forms/index.php
STUDENTS COMPLETE, SIGN, & SUBMIT ONLINE PORTAL FORMS BY AUGUST 1
Health History
Release of InformationEmergency ContactsVarsity Athletes ONLY: Sports Medical History & Sickle Cell
AUGUST 1
HEALTH INSURANCE IS MANAGED BY THE BURSAR’S OFFICE
DIRECT QUESTIONS TO:
518-580-5830
THE BURSAR’S OFFICE REQUIRES STUDENTS:
Enroll in the student health insurance plan OR
Waive with proof of comparable alternative US-based health insurance coverage.
(The Bursar’s Office will mail information on the student health insurance plan in June.)
HELPFUL INFORMATION WHEN DECIDING TO ENROLL OR WAIVE STUDENT
HEALTH INSURANCE:
Disclaimer: It is your responsibility to check with your health insurance company to
assure your current health insurance plan will cover you while in Saratoga Springs,
NY, attending Skidmore College.
Many private health insurance plans, especially HMOs, may not provide coverage for non-
emergency, out of network medical care (including laboratory services, x-rays, specialist
referrals, etc.), or may require prior authorization from your primary healthcare provider.
Adequate health insurance coverage is essential to avoid out of pocket expenses and/or
delays in accessing services in the event that off-campus medical care becomes necessary.
Will your current plan cover medical care beyond emergency services (i.e. provider’s office
visits, diagnostic testing, x-rays, prescription drugs, mental health, etc.) in the Saratoga Springs,
NY area?
Does your plan have providers, hospitals, and laboratories in the Saratoga Springs, NY area?
Check the cost – is the annual cost of the student plan less expensive than the cost of being
added as a dependent to your parents’ or guardians’ plan?
Are there administrative pre-requirements, pre-certification, or primary care provider referrals
required under your current plan that may delay receipt of care?
STUDENT HEALTH INSURANCE PLAN
https://www.skidmore.edu/bursar/health.php
STUDENT HEALTH PORTAL
All incoming students are required to register for the portal and complete portal forms.
INSTRUCTIONS TO REGISTER
1. Go to https://skidmore.studenthealthportal.com.
2. Click “NOT REGISTERED? REGISTER”.
3. Enter Skidmore ID # (include 00), birth date, security question & answer.Remember exactly how entered as answer must match when setting password shortly.
4. Click “REGISTER”.You will receive message “REGISTRATION SUCCESSFUL” and “CHECK YOUR EMAIL FORINSTRUCTIONS ON OBTAINING A PASSWORD”.
5. Check Skidmore email INBOX or JUNK/SPAM FOLDER for message from “StudentHealthPortal”with subject “Portal Registration”.
6. Click “LINK TO OBTAIN PASSWORD”.Answer security question exactly how entered before.
7. Create, verify and “SET PASSWORD”.You will receive message “PASSWORD CONFIRMATION SUCCESSFUL”.
Once you click “SUBMIT”, the form will be sent directly to Health Services and will disappear fromyour “pending forms” file.
If you experience problems with registering or completing the forms try using the latest version ofthe browser (ex. Internet Explorer, Firefox, Google Chrome, or Safari).
TROUBLESHOOTING
HELP
Contact Skidmore College Health Services (not Skidmore IT Department) for any problems youencounter with registering, logging in, completing portal forms, or error messages. We will beglad to assist you.
(518) 580-5550 or [email protected]
1. Click “CLICK HERE TO LOGIN”.
2. Enter SKIDMORE ID # (include the 00).
3. Enter password just created.
4. Click on “PENDING FORMS” in top left corner.
5. Complete forms and click “SUBMIT”.The server can “time you out” and DOES NOT save information if you remain inactive in the openform.
INSTRUCTIONS TO LOGIN
Food Allergies on Campus
Dining Services strives to provide culturally diverse, healthy food options to all students. This can be difficult for some students, especially those with food allergies. To help students navigate safely, Dining Services’ representatives are available to meet with students and parents to review menus, recipes, labels and alternate food choices for those with challenging diets.
Please feel free to reach out at any time:
Jim Rose, Executive Chef: [email protected] 518-580-8325
Joe Greco, Production Manager: [email protected] 518-580-5882
Eric DesRosiers, Kitchen Manager: [email protected] 518-580-5891
Food Allergy Guidelines https://www.skidmore.edu/diningservice/nutrition/allergies.php
1
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully.
Skidmore College Health Services uses information about you for treatment, internal administrative purposes to evaluate the quality of
care you receive, for emergency care provided by Skidmore College Campus Safety, and to help you obtain payments from your health
insurance, when necessary. In some situations, we may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits or services that may be of interest to you.
In general, a written authorization to release information is required from you to share any health information with any other party not
involved in your medical care. If you choose to sign an authorization to disclose information, you can later revoke that authorization to
stop any further uses and disclosure. You may authorize release of information specific to a date of service or an illness.
Identifiable health information may be disclosed without your authorization in certain circumstances. We are required by law to disclose
certain health information for public health purposes; incidences of suspected elder or child abuse, neglect or maltreatment; and when
directed to do so by a court-ordered subpoena. We may also disclose necessary information when a health care provider judges that a
student is in immediate danger to self or others.
1. In most cases, and according to New York State medical record laws, you have the right to review or receive a copy of your
health information. You also have a right to receive information about disclosure of health information for reasons other than
treatment, insurance, or related administrative purposes. If you believe that information on your record is incorrect, or if
important information is missing, you have the right to request a correction of the existing information. You have the right to
request restrictions on the use or disclosure of your information, but we are not required by law to agree to any such requests. If
you received this notice electronically, you have the right to receive a paper copy. Just contact us at the phone number below.
2. If you are concerned that your privacy rights have been violated, or if you disagree with a decision made about access to your
records, you may contact Health Services. You may also send a written complaint to the United States Department of Health and
Human Services. Health Services will provide you with the appropriate address upon request.
3. We are required by law to protect the privacy of your health information, provide this notice about our information practices, and
to follow the information practices that are described in this notice. We reserve the right to amend this notice, and would provide
a revised notice by campus mail.
If you have any questions or complaints, please contact Health Services at 518-580-5550.
Frequently Asked Questions and Answers About Meningococcal Meningitis
What is meningococcal meningitis?
Meningococcal meningitis is a rare but potentially fatal bacterial infection. The disease is expressed as either meningococcal meningitis, an inflammation of the membranes surrounding the brain and spinal cord, or meningococcemia, the presence of bacteria in the blood.
What causes meningococcal meningitis?
Meningococcal meningitis is caused by the bacterium Neisseria meningitidis, a leading cause of meningitis and septicemia (or blood poisoning) in teenagers and young adults in the United States. Meningitis and septicemia are the most common manifestations of the disease, although they have been expressed as septic arthritis, pneumonia, brain inflammation and other syndromes.
How many people contract meningococcal meningitis each year? How may people die as a result?
Rates of meningitis disease have been declining and in 2015, there were about 375 reported cases. About 10 to 15% of infected individuals die even with the use of antibiotics and of the survivors, about 11-19% will have some disability (deafness, loss of limb, nervous system problems). For some college students, such as freshman living in dormitories, there is an increased risk of meningococcal disease.
How is meningococcal meningitis spread?
Many people in a population can be a carrier of meningococcal bacteria (up to 11 percent) and usually nothing happens to a person other than acquiring natural antibodies. Meningococcal bacteria are transmitted through the air via droplets of respiratory secretions and by direct contact with an infected person. Direct contact, for these purposes, is defined as oral contact with shared items, such as cigarettes or drinking glasses, or through intimate contact such as kissing.
What are the symptoms?
The early symptoms usually associated with meningococcal meningitis include high fever, severe headache, stiff neck, rash, nausea, vomiting and lethargy, and may resemble the flu. Because the disease progresses rapidly, often in as little as 12 hours, prompt diagnosis and treatment are important to assuring recovery. Symptoms may appear 2 to 10 days after exposure, but usually within 5 days.
Who is at risk?
There is an increased risk of disease for young adults from age 16-21. Recent evidence indicates that college student residing on campus in residence halls appear to be at higher risk for meningococcal meningitis than college students overall. Further research released by the Centers for Disease Control and Prevention (CDC) shows freshmen living in dormitories have a six-fold increased risk for meningococcal meningitis than college students overall.
Although anyone can be a carrier of the bacteria that causes meningococcal meningitis, data indicate certain social behaviors, such as exposure to passive and active smoking, bar patronage and excessive alcohol consumption may put college students at increased risk for the disease. Patients with respiratory infections, compromised immunity, those in close contact to a known case and travelers to endemic areas of the world are also at increased risk. Cases and outbreaks usually occur in the late winter and early spring when school is in session.
Why should students consider vaccination with the meningococcal vaccine?
CURRENTLY, IN NEW YORK STATE, VACCINATION OR DOCUMENTED DECLINATION IS REQUIRED FOR INCOMING COLLEGE STUDENTS WITH MENACWY.
Pre-exposure vaccination with Menveo or Menactra (MenACWY) enhances immunity to four strains (A,C,W,Y) of meningococcus. Pre-exposure vaccination with Bexsero or Trumenba (MenB) enhances immunity to one strain (B) of meningococcus. Serotypes B, C, and Y are responsible for the majority of meningitis cases in the United States. Serotype B is responsible for ~ 60% of meningitis cases in children less than 5 years old. Serotypes C, Y, and W are responsible for about 66% of all cases in children 11 years old and older. Serotype A is more prevalent in developing countries as in the meningitis belt in sub Saharan Africa.
MenB is recommended for certain categories of people with immune system disorder or those working with meningococcus bacteria in laboratories. Your primary care physician can help you decide which meningitis vaccine to receive.
How effective is the vaccine?
MenACWY vaccine is 85 to 100 percent effective in preventing infection from subtypes ACWY. Currently, the effectiveness of MenB is estimated to be 63-88%.
Is the vaccine safe? Are there adverse effects to the vaccine?
The vaccine is very safe and adverse reactions are mild and infrequent, consisting primarily of redness and pain at the site of injection lasting up to two days.
Where can I get the meningococcal vaccine?
Your local health care provider or county health department should be able to offer you the vaccine.
What is the duration of protection? Protection provided by meningococcal vaccine (MCV4) wanes within 5 years following vaccination. At this time, CDC recommends “initial meningococcal vaccine at age 11-12, followed by a booster at age 16 to provide continued protection during peak years of vulnerability.” As with any vaccine, vaccination against meningitis may not protect 100 percent of all susceptible individuals.
How do I get more information about meningococcal disease and vaccination?
Contact your healthcare provider or Skidmore College Student Health Services at [email protected]. Additional information is also available on the websites of the New York State Department of Health, www.health.state.ny.us; the Centers for Disease Control and Prevention (CDC), www.cdc.gov/meningococcal, and www.cdc.gov/vaccines/hcp/vis/index.html; and the American College Health Association (ACHA), www.acha.org.
ᶥ Updated Recommendations for Use of Meningococcal Conjugated Vaccines – Advisory Committee on Immunization Practices (ACIP), 2010; January 28, 2011/Volume 60 (03); 72-6, https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6003a3.htm. Vaccine Information Statement, Meningococcal, Centers for Disease Control and Prevention, January 28, 2008, www.cdc.gov/vaccines/hcp/vis/index.html. Meningitis Disease: Technical and Clinical Information. 2017. https://www.cdc.gov/meningococcal/clinical-info.html.
SKIDMORE COLLEGE HEALTH SERVICES Phone: (518) 580-5550 815 N. Broadway Fax: (518) 580-5556 Saratoga Springs, NY 12866
S T E P 1
TUBERCULOSIS SCREENING/TESTING FORM Student Name: Birth Date: / /
STUDENT MUST ANSWER THE FOLLOWING QUESTIONS.
□ Yes □ No Are you an international student?
□ Yes □ No Were you born in OR have you had frequent or prolonged visits to AFRICA, ASIA (including China & Korea), EASTERN EUROPE OR LATIN AMERICA? The significance of the travel exposure should be discussed with healthcare provider & evaluated.
□ Yes □ No Do you have a history of positive PPD skin test or IGRA blood test?
□ Yes □ No Have you ever had close contact with persons known or suspected to have active TB disease?
□ Yes □ No Have you been a resident and/or employee of high-risk congregate settings (e.g. correctional facilities, long-term care facilities & homeless shelters) or served clients at high risk for active TB disease?
□ Yes □ No Have you ever been a member of any of the following groups that may have an increased incidence of latent M. tuberculosis infection or active TB disease—medically underserved, low-income, or abusing drugs or alcohol?
→ IF YOU ANSWERED “NO” TO ALL QUESTIONS, YOU ARE CONSIDERED LOW RISK. HEALTHCARE PROVIDER MUST REVIEWANSWERS WITH YOU & SIGN FORM.
→ IF YOU ANSWERED “YES” TO ANY QUESTIONS, PROCEED TO STEP 2 FOR ADDITIONAL EVALUATION TO EXCLUDE ACTIVETUBERCULOSIS DISEASE.
PROVIDER ASSESSMENT—TB SYMPTOM CHECK □ Yes □ No Does student have any of the signs or symptoms of active pulmonary tuberculosis disease—cough for 3 weeks
or longer with or without sputum production, chest pain, unexplained weight loss, fever, coughing up blood, loss of appetite, or night sweats?
REGARDLESS OF ANSWERS TO TB SYMPTOM CHECK, PROCEED TO EITHER PPD (TST-Tuberculin Skin Test) OR IGRA. REQUIRED within 6 months prior to arrival on campus (no earlier than February 1, 2019).
PPD OR MANTOUX Result should be recorded as actual millimeters (mm) of induration, transverse diameter. If no induration, write “0”. The interpre-tation should be based on mm of induration as well as risk factors.
Date Given: ____/____/____ Date Read: ____/____/____ Result: ________ mm of induration *Interpretation: ___positive ___negative
M D Y M D Y (*see back page)
OR INTERFERON GAMMA RELEASE ASSAY (IGRA): A history of BCG vaccination should NOT preclude testing of a member of a high risk group.
Date Obtained: ____/____/____ Specify Method: QFT-GIT or T-Spot Result: ____negative ____ positive ____indeterminate ____borderline M D Y
→ IF NEGATIVE RESULT, HEALTHCARE PROVIDER MUST SIGN FORM.
→ IF POSITIVE RESULT, PROCEED TO STEP 3.
S T E P 2
CHEST X-RAY REQUIRED if either the TST or IGRA result is positive, there is a past history of a positive tuberculosis test, or patient is experiencing signs or symptoms of active pulmonary tuberculosis disease. Date: ____/____/____ Result: ___normal ___abnormal
M D Y
PREVENTATIVE OR THERAPEUTIC TUBERCULOSIS TREATMENT IF INDICATED Medication(s) - Please list: Dates Taken: Medication(s) - Please list: Dates Taken:
Treatment offered but student declined.
PROVIDER INFORMATION & SIGNATURE REQUIRED Address (print or stamp)
Name & Title of Healthcare Provider (please print)
Provider Signature
Phone: (______) ___ Fax: (______) _
S T E P 3
RETURN SIGNED FORM TO HEALTH SERVICES—FAX 518-580-5556, EMAIL [email protected], or mail.
Date:
*Interpretation guidelines
>5 mm is positive in:
recent close contacts of an individual with infectious TB
persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of prednisone for > 1month)
HIV-infected persons
>10 mm is positive in:
recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant amount of time
injection drug users
mycobacteriology laboratory personnel
residents, employees, or volunteers in high-risk congregate settings
persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus, chronic renalfailure, certain types of cancer (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or jejunoileal bypass andweight loss of at least 10% below ideal body weight
>15 mm is positive in:
persons with no known risk factors for TB
IMMUNIZATION RECORD
Student Name: Birth Date (mm/dd/yy): / /
1. REQUIRED IMMUNIZATIONS Date format MM/DD/YY MMR (Measles, Mumps, & Rubella)—NYS Health Department Law
1st dose required after 1st birthday and 2nd dose required at least 28 days after 1st dose OR
MMR #1: / /
MMR #2: / /
IF MMR NOT GIVEN NYS Health Department Law requires the following: MEASLES
1st dose required after 1st birthday AND 2nd dose required at least 28 days after 1st dose AND
MUMPS 1 dose required after 1st birthday AND
RUBELLA 1 dose required after 1st birthday OR
IMMUNE TITER RESULTS FOR MEASLES, MUMPS, RUBELLA Attach lab reports
Measles #1: / / Measles #2: / /
Measles Titer: / /
Mumps #1: / /
Mumps Titer: / /
Rubella #1: / /
Rubella Titer: / /
MENINGITIS—MENACTRA OR MENVEO (ACWY) 1st dose over age 12 2nd dose over age 16 OR 1 dose within the last 5 years
Meningitis #1: / /
Meningitis #2: / /
TETANUS-DIPTHERIA-PERTUSSIS—Most recent booster TD or Tdap Required within last 10 years
TD : / / Tdap: / /
2. RECOMMENDED IMMUNIZATIONS Date format MM/DD/YY
Meningococcal B: Bexsero
Men B #1: / / Men B #2: / / OR
Meningococcal B: Trumenba
Men B #1: / / Men B #2: / / Men B #3: / /
Hepatitis A #1: / /
Hepatitis A #2: / /
Hepatitis B #1: / /
Hepatitis B #2: / /
Hepatitis B #3: / /
HPV (Human Papilloma Virus)
Gardasil #1: / /
Gardasil #2: / /
Gardasil #3: / /
Polio: (circle one) IPV OPV Primary series completed: / / Additional dose post completion of primary series
(if applicable): / /
Varicella (Chickenpox)
Varicella #1: / /
Varicella #2: / / OR
History of Chickenpox: _____Yes _____ No
Other Immunizations (most recent date)
Rabies (date series completed) / / Typhoid (injectable) / / Typhoid (Oral) / / Yellow Fever / /
STATEMENT OF EXEMPTION TO NEW YORK STATE IMMUNIZATION LAW
□ Religious Exemption:Student or parent/guardian (if student is under theage of 18) adheres to a religious belief opposed toimmunizations and must submit statement accordingto policy on Health Services website.
□ Medical Exemption:The physical condition of the above named person issuch that immunization would endanger life orhealth, or is medically contraindicated due to other
PROVIDER INFORMATION & SIGNATURE REQUIRED ___________________________________________ Name & Title of Healthcare Provider (please print)
___________________________________________ Provider Signature Date
Address (print or stamp)
___________________________________________
___________________________________________
___________________________________________
Phone: (_____) _____________ Fax: (_____) ______________
SKIDMORE COLLEGE PHYSICAL EXAMINATION FORM
Student’s Name: Last: First: Middle Initial: Date of Birth:
Vital Signs: Ht: Wt: B/P: PULSE:
Medications: Allergies:
Past Medical History:
Item/Area Evaluated Normal Not Examined Abnormal If Abnormalities Are Noted, Please Describe
Appearance
Nose & Sinuses
Mouth & Throat
Teeth & Gingiva
Ears
Eyes
Neck
Lungs
Heart
Vascular
Abdomen
Ano-rectal
Genitalia
Upper Extremities
Lower Extremities
Spine
Neurologic
Tuberculosis: Low Risk High Risk (as determined by answers on Tuberculosis Screening/Testing Form)
Comments about previous problematic joints?
Any physical stigmata of Marfan’s Syndrome?
CLEARANCE FOR PARTICIPATION IN:
All sports without restriction
Cleared after completing evaluation/rehabilitation for:
Not cleared for:
Reason:
Recommendations:
PROVIDER INFORMATION & SIGNATURE REQUIRED
I have conducted a physical examination of this patient
within the past year (AFTER 08/01/18). All medical/psychiatric conditions and therapies are noted above or on attached pages.
Date of Exam: _____/_____/_____
Print Provider Name:
Address (Please print or stamp):
Phone # (_____) _____ _____ Fax # (_____) _____ _____
Signature of Healthcare Provider Degree