MLT Student Health Form
PART II
Howard Community College
Health Science Division
Student
Indicate
Program:___________
Please complete all sections of this form and return to
Health Sciences Division Office HS 236
Name:
HCC ID#:________________
HEALTH FORM DEADLINES
Completed Health Form must be submitted prior to the following dates.
Late submissions may result in forfeiture of seat.
(If deadline falls on a holiday/weekend, paperwork is due the following business day.)
Program
Medical Laboratory
Technician
THIRD SEMESTER
CLINICAL ROTATION
Due Date
December 10
Criminal Background/Urine Drug Screen
Complete Between:
November 6 - December 10
Questions – Health Sciences Division Clinical Liaison
HOTLINE: 443-518-1561
EMAIL: hsdcc@howardcc.edu
Offices: HS 353 & HS 354
You may scan/email or FAX your Health Information.
You must also submit a copy of current CPR and Criminal Background & Urine Drug Screen Email Order
Confirmation with Health Form.
Make a copy of your paperwork PRIOR to submission.
You will not have access to the forms once they have been turned in.
MLT Part II. STUDENT HEALTH FORM – Fall.2015
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IMPORTANT
•
Sections on pages 4, 5 and 7 MUST be completed by a licensed health care provider.
•
Incomplete submissions may not be processed.
•
Late health forms may result in Forfeiture of Seat.
•
The Physician, Physician Assistant or Nurse Practitioner’s signature is required on this form
•
Student signatures are required under Hepatitis Vaccination/Waiver, Health Sciences Policies and Student
Release of Information on pages 4, 6, and 9.
•
A photocopy of your CPR card (front and back) must be submitted along with this paperwork. Only
American Heart Association BLS for Healthcare Provider will be accepted.
•
Students should be aware that some facilities may not accept the moral waiver for the Seasonal Flu vaccine
which may lead to failure of the course.
MLT Part II. STUDENT HEALTH FORM – Fall.2015
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10901 Little Patuxent Pkwy.
Columbia, MD 21044-3197
443-518-1000
MD Relay 711
www.howardcc.edu
To whom it may concern:
Please be aware that, according to CDC guidelines, healthcare providers and students of Health
Sciences programs must have proof of immunity from titers. History of disease and vaccination
history are not acceptable for our program.
Please order the following:


Titers:
IgG EIA Measles Antibody
IgG EIA Mumps Antibody
IgG EIA Rubella Antibody
IgG EIA Varicella Antibody
If the student has either an equivocal or negative serologic test result, proof of a
booster is required. IgM tests are not required.

The student must have a documented initial Two-Step PPD skin test. (Second
PPD is to be done 1-3 weeks after first PPD reading has been done.)

A single PPD is required every year thereafter.

Students with a history of a positive PPD or BCG vaccine should submit a copy
of the Chest X-Ray Report as well as a Tuberculosis Questionnaire (included see
page 5). The Tuberculosis Questionnaire is required every year thereafter.
Thank you for your assistance in this matter. Feel free to contact us with any questions.
Sincerely,
Health Sciences Division Clinical Coordinators
Howard Community College
443-518-1561
Nursing Files\STUDENT HEALTH FORM -- Revised 7-01-2015
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STUDENT NAME: _________________________________________________
SECTION I: ATTACH All Current Titer, and Booster Lab results to the last page of Health Form, or
this form will not be accepted. (SUBMIT ACTUAL LAB VALUES.)
Immunity Status (To Be Completed by Licensed Health Care Provider)
Measles, Mumps, and Rubella (MMR):
Titre Date:
If MMR Titre result was negative or equivocal,
the booster is required.
Booster Date:
----------------------------------------------------------------------------------------------------------------------------------------Varicella:
Titre Date:
If Varicella Titre result was negative or equivocal,
then booster is required.
Booster Date:
History of disease is not sufficient.
----------------------------------------------------------------------------------------------------------------------------------------SECTION II. Tuberculosis
(To Be Completed by Licensed Health Care Provider)
All students entering the HCC Health Sciences Division programs must have a documented initial Two-Step PPD
skin test. Second PPD to be done 1-3 weeks after first PPD reading has been done. A single PPD is required
annually thereafter. Students with a history of a positive PPD skin test or BCG vaccination should submit a Chest
X-ray report and complete the Tuberculosis Questionnaire. All students are required to provide a PPD or
questionnaire annually.
Part I.
PPD Skin Test – (Due annually)
Date of first PPD Skin Test:
Date of second PPD Skin Test:
Part II.
Date Read:
Date Read:
If PPD Skin Test is Positive or history of BCG vaccine
Date of Chest X-Ray (only has to be done once):
Part III.
Results:
Results:
Report (attach copy):
Tuberculosis Questionnaire – (Due annually)
A Licensed Health Care Provider must complete this form. This Questionnaire is to be utilized if the student has a
positive PPD Skin Test or a history of BCG vaccine.
Tuberculosis Questionnaire
Does the student have a fever?
Does the student get tired easily?
Does the student have any Chest Pain or Shortness of Breath?
Is the student experiencing any chills or night sweats?
Has the student had any loss of appetite?
Has the student has any sudden unexplained weight loss?
Has the student had a productive or prolonged cough lasting > 3 weeks?
If the student has a cough, are they spitting up blood?
Nursing Files\STUDENT HEALTH FORM -- Revised 7-01-2015
Yes
No
5
10901 Little Patuxent Pkwy.
Columbia, MD 21044-3197
443-518-1000
MD Relay 711
www.howardcc.edu
Seasonal Flu
Vaccination Verification Form
Name:
This form must be completed by a licensed health care provider.
HCC ID #:
Date Administered:
Injection Site:
Name of Health Care Provider:
Signature of Health Care Provider:
Name of Administering Facility:
Phone Number of Administering Facility:
Section IV.
Signature
Health Care Provider Recommendations and
I have given the student
, a complete history and physical
exam and I consider the student mentally and physically able to participate in the Howard Community College
Health Sciences program.
Provider’s Name:
Date:
Office Address:
Phone Number:
Signature of Licensed Health Care Provider:
Nursing Files\STUDENT HEALTH FORM -- Revised 7-01-2015
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Health Sciences Programs
STUDENT RELEASE OF INFORMATION FORM
Enrollment and participation in the Health Sciences Programs at Howard Community College (HCC) require that
students provide proof of general and specific health status, immunization records, CPR certification, criminal
background check, social security number, driver's license/photo identification card, academic records, urine/blood
tests for drug screening and any other information that may be required by the college or clinical facility policy or
legal mandate to establish students’ fitness to care for live patients in a clinical setting.
The Health Sciences Division is required to share this information with clinical facility partners who provide the
sites for the required clinical training portions of the courses. Pursuant to the Family Educational Rights and
Privacy Act of 1 74, 20 U.S.C. 1231g (“FERPA”), the college may not release information without the written consent
of the student; subject to the exceptions specified under FERPA. You may obtain more information about Student
Rights and Responsibilities (FERPA) from your course catalog, student handbook, or college website
www.howardcc.edu/admissions/register/ferpa. The clinical facilities are required to maintain the confidentiality of
these records and may only use them to determine that a student meets the standards of the institution and thus does
not present a threat to their patients or staff.
Choosing to not provide permission for the release of this information will prohibit participation in HCC Health
Sciences Programs as it will result in a ban from the clinical facilities where students are required to complete the
clinical portion of training. Admission to and successful completion of the clinical training portions of Health Sciences
courses are required for program enrollment and completion.
NAME OF STUDENT (Last, First, Middle Initial):
HCC ID NUMBER:
I understand that some of my records are protected under the Family Educational Rights and
Privacy Act of 1974 and cannot be released without my written consent. I hereby grant permission
for release of all applicable records described above to clinical facilities and grant access to those
records by agents of those clinical facilities as required for my participation and completion in the
HCC Health Sciences Program in which I am or intend to be enrolled. I certify that this consent has
been given freely and voluntarily. I may revoke this consent at any time by providing written notice
of such revocation to HCC Health Sciences Division. I understand that revocation of this consent
will result in ineligibility to enroll in and/or continue in any HCC Health Sciences Program. This
authorization is in effect for the duration of my participation and enrollment in HCC Health
Sciences Program courses unless revoked in writing, and photocopies of this release form may be
accepted, when presented in person with appropriate identification.
Student Signature
Nursing Files\STUDENT HEALTH FORM -- Revised 7-01-2015
Date
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