교환 / 입학 / 재학중인국제학생들을위한의료요구사항 다음은코네티컷주립대학학생보건서비스양식입니다. 양식의양면을작성해주시기바랍니다. 첫번째페이지의모든항목은필수기입사항입니다. 두번째페이지의학생이작성하는내용은 CCSU 에진학해있는기간동안의료도움을요구할시도움이될것입니다. 코네티컷주립대학은학생예방접종양식복사본을허용하지않습니다. 다음코네티컷주립대학학생보건서비스양식은의무적으로작성해야하며예방접종의증거로인정되는유일한양식입니다. 이양식에관한위의사항을의료진에게분명히확인하시기바랍니다. 1) 필수예방접종 ( 자세한정보는다음페이지참고 ): 코네티컷주법과 CCSU 에서는모든재학생과입학생에게다음예방접종증명을요구합니다 : a) 홍역 (measles), 유행성이하선염 (mumps), 풍진 (Rubella-MMR); 그리고 b) 수두 (varicella-chicken pox) 기숙사에서거주하는학생들은수막염으로인한질병 (meningococcal disease) 에대한예방접종을해야합니다. 미국은이예방접종의 A, C, Y, W 135 타입을요구합니다. 이접종들은모든학생의출생한국가에서사용하는것은아닙니다. 기숙사입주전위의네가지타입의백신이들어가있는예방접종을맞아야합니다. 수막염예방에대한자세한내용은홈페이지 www.ccsu.ed/health 에서 Important Medical Updates 란혹은수막염예방접종업데이트에서확인할수있습니다. 또한학생에게간염예방접종완료와지난 10 년내에촬영파상풍부스터접종을권유합니다. 2) 결핵검진 : CCSU 에서는결핵리스크평가 (TB Risk Assessment) 를요구합니다. 결핵리스크평가를통해결핵검진 ( 피부검사혹은혈액검사 ) 이필요한지신중하게검토하십시오. 결핵검진을필요로할경우 CCSU 재학 6 개월이내에미국에위치한의료기관에서검사해야합니다. 3) 신체검사양식 : 이양식에의료진의서명이있어야합니다. 대학보건서비스 (s) 에서는결핵검사, MMR, 수두, 그리고수막염질병예방접종을제공합니다. 추가예방접종은학교오피스에서제공됩니다. 검사와예방접종에대한수수료는학생계좌로청구됩니다. 요구되는모든정보와자료를대학보건서비스로가장빠른시일혹은캠퍼스도착최소 2 주내에제출해주시기바랍니다. 추가적인의료정보가필요할경우학생거주국가에서의료정보를얻을수있도록전산이메일을통해통지하겠습니다. 위의사항에맞지않거나필요한양식을제출하지않을경우수업등록, 변경과기숙사의입주를못할수있습니다. 이러한문제가발생하지않도록, 질문이있을경우 860-832-1925 로문의바랍니다. 의료보험고려사항 코네티컷주립대학생들은최소대학에서제공하는 Aetna 학생의료보험과같거나, 또는초과커버가능한보험유지는필수사항입니다. 본인개인의의료보험을소지하고있을경우학교의보험을포기할수도있지만, 대학주위의모든의료기관에서각자개인이가지고있는보험을받는것은아닐수도있다는점을참고하시기바랍니다. 이는추후개인에게모든의료청구금액의책임이있을수있으며, 따라서적용가능한보험을소지하지않을경우의료진이검진을거부할수
있습니다. 이에국제교육센터와대학보건서비스에서는모든유학생에게대학에서제공하는 Aetna 학생보험가입을권장합니다. 의료보험에대한상세한정보는 www.ccsu.edu/health 에서찾을수있습니다. 대학보건서비스는여러분이성공적으로학업의여정을마치는데도움이되고자만들어진기관입니다. 필요한정보를얻고자하거나긴급사항발생시에는 (860) 832-1925 로문의하시기바랍니다. 또한 CCSU 홈페이지 www.ccsu.edu/health 방문하셔서저희가제공하는서비스를확인바랍니다. CCSU 입학을축하합니다! 대학보건서비스 크리스토퍼다이아몬드, MD, 디렉터 마리솔아폰테, APRN, 부디렉터 KOREAN TRANSFER/EXCHANGE Revised 12/22/10; 8/11;3/13
예방접종필요 / 불필요증빙서류사항 코네티컷일반법령및 CCSU 는재학중인모든학생들에게다음을요구합니다. 홍역 (Rubeola) 면역력증명서 : 아래중한가지증빙을필요로합니다. 두차례의홍역혹은 MMR 예방접종 (1 세이후한차례와첫번째예방접종이후한달후 ); 혹은 홍역양성반응혈액검사결과 풍진 (Rubella) 면역력증명서 : 아래중한가지증빙을필요로합니다. 두차례의풍진혹은 MMR 예방접종 (1 세이후한차례와첫번째예방접종이후한달후 ); 혹은 풍진양성반응혈액검사결과 유행성이하선염 (Mumps) 면역력증명서 : 아래중한가지증빙을필요로합니다. 두차례의유행성이하선염혹은 MMR 예방접종 (1 세이후한차례와첫번째예방접종이후한달후 ); 혹은 유행성이하선염양성반응혈액검사결과 수두 (Varicella-chicken pox) 면역력증명서 : 아래중한가지증빙을필요로합니다. 두차례의수두예방접종 ; 혹은 수두양성반응혈액검사결과 홍역, 풍진, 유행성이하선염, 혹은수두를앓았던기록이있으면그공식의료기록을제출하여도됩니다.. 기숙사배정을받기전모든학생은수막염 (Meninggococcal) 예방접종증빙서류 ( 메낙트라 ) 를제출해야하며, 미제출시 캠퍼스기숙사로입주할수없습니다수막염예방접종은기숙사에거주하는않는모든재학생들에게도강하게유구하고 있습니다. 만약, 현재마지막예방접종날짜후 5 년이지났다면담당의사와확인후부스터주사를받는게좋습니다. B 형간염 : 미국대학보건협회, 코네티컷보건부, 그리고질병통제예방센터는학생들이 B 형간염예방접종을받기를 권합니다. ( 필수요건은아님 ) 파상풍 (Tetanus): 10 년에한차례부스터주사를권고합니다. 예방접종면제 1957 년 1 월 1 일전출생한학생은홍역, 유행성이하선염, 풍진요구사항에서면제됩니다. 1980 년 1 월 1 일전출생한학생은수두요구사항에서면제됩니다. 종교또는의료상이유의예방접종면제허용이가능합니다. www.ccsu.edu/health/forms 에서자세한사항을볼수있습니다. 의료상혹은종교적인이유로예방접종면제를받는경우, 만일예방접종을요하는질병발생시그당사자는캠퍼스에서퇴거, 출입이제한될수있습니다. 온라인학습자에게는예방접종사항이적용되지않습니다. KOREAN TRANSFER/EXCHANGE Revised 12/22/10; 8/11;3/13
Connecticut State University Student Health Services Form Beginning School Fall Spring of PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS Last Name First Name MI FOR OFFICE USE ONLY Complete Missing: BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED of Birth and Birthplace: Sex/Gender: Student ID #: State of Connecticut and Connecticut State Universities REQUIRE: Two doses for each Measles, Mumps, Rubella & Varicella One dose of Meningitis* Complete TB Risk and/or Test or Treatment Vaccine & Given OR Incidence of OR Requirements Disease Titer Test Results (attach lab report) 1 Measles #1 or MMR Measles Titer : Measles #2 or MMR 2 Mumps #1 or MMR Mumps Titer Mumps #2 or MMR 3 Rubella #1 or MMR Rubella Titer Rubella #2 or MMR 4 Varicella #1 OR Incidence of OR Varicella Titer Disease Chicken Pox Varicella #2 Provider Initials: 5 Meningococcal Vaccine Type or Brand: : 6 TUBERCULOSIS (TB) RISK QUESTIONNAIRE - A through D To be answered by the Student A. Have you ever had a positive tuberculosis skin or blood test in the past? If you answer, Yes, Section 6b., CHEST X-RAY, must be completed *Required only if living in university owned housing. Varicella is required only for students born on or after January 1, 1980 #1 Must be on or after 1 st birthday; #2 Must be at least 28 days after 1 st immunization I will not be living in University owned housing. I do not require this vaccine. B. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)? Yes No C. Were you born in one of the countries listed below? If yes circle country Yes No D. Have you traveled or lived for more than one month in one or more of the countries listed below? If yes circle country. Yes No Afghanistan, Algeria, Angola, Armenia, Azerbaijan, Bangladesh, Belarus, Benin, Bhutan, Bolivia, Bosnia & Herzegovina, Botswana, Brunei Darussalam, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, China,China-Macao, China-Hong Kong, Congo, Congo DR, Cote d Ivoire, Djibouti, Dominican Rep., Ecuador, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Georgia, Ghana, Guatemala, Guinea, Guinea- Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iraq, Kazakhstan, Kenya, Kiribati, Korea-DPR, Korea-Rep, Kyrgyzstan, Lao PDR, Latvia, Lesotho, Liberia, Lithuania, TFYR, Madagascar, Malawi, Malaysia, Mali, Marshall Islands, Mauritania, Micronesia, Moldova-Rep, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Niger, Nigeria, Northern Mariana Islands, Pakistan, Papua New Guinea, Paraguay, Palau, Peru, Philippines, Qatar, Romania, Russian Federation, Rwanda, Sao Tome & Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sri Lanka, Sudan, Suriname, Swaziland, Taiwan, Tajikistan, Tanzania-UR, Thailand, Timor-Leste, Togo, Turkmenistan, Tuvalu, Uganda, Ukraine, Uzbekistan, Vanuatu, Vietnam, Yemen, Zambia, Zimbabwe Based on WHO Global TB Report 2009 6. IF you answer NO to all questions no further action is required. Prior BCG does not exempt patient from this requirement. IF you answer YES to B-D of the above questions, Connecticut State University requires that a healthcare provider complete the following TB testing evaluation and x-ray within 6 months prior to the start of classes. (After February for Fall Semester and after July for Spring Semester.) 6a. TB BLOOD TEST OR Interferon-gamma release assay Result: NEG POS 6a. TB SKIN TEST Use 5TU Mantoux test only. TB skin tests ARE NOT ACCEPTED from other countries. Planted: Read: Interpretation (If no induration, mark 0) NEG POS mm of induration 6b. CHEST X-RAY Required within 6 months for past or current positive TB skin or blood test. X-ray report MUST BE ATTACHED Chest X-ray Normal Abnormal Yes No 6c. TB TREATMENT MEDICATION (with dose): Frequency: Start & Completion s: Other Vaccination History (Tetanus Booster within last 10 years and Hepatitis B series are recommended) Hepatitis B #1 Hepatitis B #2 Hepatitis B #3 Hepatitis Titer Result: POS NEG Last Tetanus Booster: Td or Tdap Other Vaccination: Other Vaccination: Other Vaccination: Signatures I confirm that the information above is accurate. Clinician Signature: Physical Examination Affirmation: I have examined this patient on and find no medical condition that would prohibit him/her from participating fully in all activities including physical education, trying out for competitive sports or military training and employment. Clinician Signature: Consent for treatment required to be signed (If you are less than 18 years of age signatures of both the student and one parent/guardian are required) I hereby grant permission for the Connecticut State s staff to provide me with appropriate medical and mental health treatment including medications for treatment of illnesses/injuries and to arrange for any emergency medical care if circumstances at that time make it impossible for me to make such decisions. Furthermore, I understand that University Health Services staff may disclose my student medical records and/or information from such records to appropriate University personnel and/or Emergency Contacts identified within my records in the event of a health or safety situation as determined by the Student Health Services staff. Signature of Student Signature of Parent/Guardian Continue to Page 2
Connecticut State University Student Health Services Form Page 2 PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED Student Name Home/Personal Email Address Student Cell Phone Permanent Home Information Notify in Case of Emergency Home Phone Cell/Work Phone Name Relationship Street Address Home Phone Cell/Work Phone City State Zip Street Address Name: Personal Physician/Healthcare Provider City State Zip Address: Telephone #: FAX # Personal Medical History- Please circle all below that apply to you Check here if none apply Alcohol/drug Abuse Diabetes Mumps Anxiety/depression/mental illness Endometriosis Rheumatic Fever Asthma Gastrointestinal Problems Seizures Cancer Hepatitis B or C Disease Sickle Cell Anemia Cardiac Condition/Heart Murmur High Blood Pressure Thyroid Disorder Coagulation Disorder HIV/AIDS Tuberculosis Concussion Measles Other please explain Dental Problems Mononucleosis Allergies: Drugs & Other Severe Adverse Reactions - Please complete all that apply and explain reaction Check here if you have no allergies Medication Food Insect Seasonal Environmental X-ray Contrast Are any life threatening? Yes No Do you carry an Epi Pen? Yes No Prior Hospitalizations or Surgeries - Please list dates and reasons Medications Frequent or regular- Please list all prescriptions, natural and over the counter medications Is there any other medical information or health concern that we should know about? Please attach any additional information to further explain your condition or concern. Current Height**: Current Weight**: Last Blood Pressure (if known)**: **not required Did you sign the Consent for Treatment on Page 1? Please return by mail or fax to the appropriate Health Service listed below. Central Connecticut State University 1615 Stanley Street New Britain, CT 06050 860/832-1925 Fax 860/832-2579 Eastern Connecticut State University 185 Birch Street Willimantic, CT 06226 860/465-5263 Fax 860/465-4560 Southern Connecticut State University 501 Crescent Street New Haven, CT 06515 203/392-6300 Fax 203/392-6301 Western Connecticut State University 181White Street Danbury, CT 06810 203/837-8594 Fax 203/837-8583 Revised 01/14/11