Dear Hope Student,
Congratulations on your acceptance to Hope College! We look forward to meeting you. This letter is to
inform you about the immunization and tuberculosis screening procedures we require for all incoming students.
Enclosed you will find a health history form outlining the required immunizations. There is an additional letter
explaining the minimum immunization requirements as well as some commonly asked questions. Do let me
know if you still have any specific questions.
Tuberculosis screening is performed on all incoming students, not just international students. This screening is
important to both identify active disease and past exposure to tuberculosis (TB). The Hope Health Center
follows the U.S. Center for Disease Control guidelines for evaluation and treatment of tuberculosis. We require
that you have this screening and testing done here at Hope College upon your arrival. Please do not have this
test done in your home country before departing for the U.S. as we cannot accept these results. Please note that
having received BCG vaccine in the past does not change the recommendations for screening, testing or followup for tuberculosis.
If you should have a positive TB test, you will have a chest x-ray to rule out the possibility of active or
infectious TB. Once active TB is ruled out, our public health physician will provide information to you
regarding Latent Tuberculosis Infection (LTBI). To decrease the risk of developing active TB disease, you will
be required to participate in treatment for LTBI. This involves taking a daily medication for 9 months. This
medication will be provided to you without cost and you will be able to receive it at the Hope Health Center.
Please note that LTBI treatment is a requirement to attend classes and continue your living
arrangements at Hope College. Failure to do so will result in your withdrawal.
Upon your arrival I will be available to answer any questions that you may have. If you have questions prior to
your departure please address them to me through the International Student Office (intladvisor@hope.edu). I
wish you safe travels and our staff looks forward to being of service to you while you are here at Hope College.
Sincerely,
Cindy L. Sabo, RN-C, BSN
Hope Health Center
Clinic Manager
sabo@hope.edu
Dear Health Care Provider and/or Hope Student,
Our immunization requirements for Hope College are based upon the Centers for Disease Control guidelines.
Here is a list of the MINIMUM requirements for each required vaccine:
Vaccine
Minimum
number of doses
Minimum
Spacing requirements
Tetanus
3
Diphtheria
3
Pertussis
1
1 dose after the age of 10 years
Polio
3
1 month between each dose
Measles/Mumps/Rubella
Single or combination
vaccine(s) accepted.
2 doses of
each component
Hepatitis B
3
Meningococcal
Conjugate (MCV4)
1
Dose #1 – Dose #2: 4 weeks
Dose # 2 – Dose #3: 6 months
Last dose given within past 10 years.
First dose must be after age of 1 year.
Second dose must be no sooner than
28 days after dose 1.
Dose # 1 – Dose # 2: 28 days
Dose # 2 – Dose # 3: 2 months
Dose # 1 – Dose # 3: At least 4 months
1 dose on or after age of 16 years.
Booster dose required if first dose given
before age 16.
Approximate cost to have
vaccine at Hope College
Combination
Tetanus/Diphtheria
$25.00
T/d combination with
Pertussis $40.00
IPV $30.00
Combination MMR
$60.00
Under age 20 $20.00
Age 20 and up $40.00
$100.00
Commonly asked Questions
What if I can’t produce a written record of my immunization history?
•
•
Students who cannot produce a written record with their immunization history must re-start the above
vaccines to complete the minimum requirements.
This will then provide the student with written documentation for Hope College and any future needs,
such as graduate school.
What if I start on the vaccines at home, but cannot complete them before I have to leave for Hope
College?
•
Students may start the above vaccines at home and may complete them once they are here at Hope
College.
What if I cannot obtain the vaccine in my home country.
•
•
Students may obtain any of the required vaccines at Hope College when they arrive.
The fees may be covered under their HopeHealth benefit.
What if I do not want the required immunizations?
•
•
Students may sign an immunization waiver. This can be obtained at
http://www.hope.edu/admin/healthcenter/Immunization%20Waiver.pdf
Please pay close attention to the travel restrictions and disease outbreak guidelines for those that choose
to sign the waiver form.
What if I have more questions?
•
•
General immunization guidelines and information can be obtained at
http://www.cdc.gov/vaccines/recs/schedules/
Specific questions regarding Hope College guidelines can be addressed to healthcenter@hope.edu. One
of our Registered Nurses will reply to your specific question.
Hope College Health Center
Health History Form
For our
International Students
International Office
141 E. 12TH STREET
P.O. Box 9000
HOLLAND, MI 49422-9000
Fax: 616-395-7937
one semester
I will be studying at Hope for (circle one):
Country I am arriving from:
one year
2-3 years
4 years
Instructions: This form is a requirement for entry to Hope College and Treatment in the Health Center.
1. Complete top boxes. Submit a copy of your immunization record ...OR…have your health care provider complete
immunization history form below. Refer to attached sheet for minimum immunization requirements.
2. Backside is to be completed and signed by the Hope student.
3. Return form by mail or fax to Hope International Office, at the above address, BEFORE July 1, 2013.
NOTE: All information is confidential and not part of academic records. The information is only accessible to the staff of
the Health & Counseling Services, unless written authorization is provided in compliance with HIPAA
Last Name
First Name
Middle Initial
Permanet Home Address (Street, City, State/Province, Country)
Age
Birthdate (month, date, year)
Female
Male
Home Telephone with country or area codes
Required Immunizations for Participation at Hope College
Tetanus/Diphtheria/
Pertussis
Measles/
Mumps/
Rubella
Dates Tetanus received:
Dates Measles
(Rubeola)
Received:
Dates Diphtheria received:
Dates Mumps
received:
Dates Rubella
received:
Date(s) Pertussis received:
For office use only:
Chickenpox (Varicella)
I had this disease at age
_________ or year_____
--OR-2 doses of Varicella
Vaccine if no history of
disease:
Varicella #1
Varicella #2
Submission of antibody titres
showing immunity is acceptable in
lieu of vaccines.
Please include copy of lab results
showing immunity.
Submission of
antibody titres
showing immunity is
acceptable in lieu of
vaccines.
Please include copy
of lab results showing
immunity.
Dose # 1
Dose # 2
HPV
Dose # 1
Dose # 2
Dose # 3
Typhoid
Dose #1
Dose # 2
Indicate oral or IM
Dose # 1
Dose # 2
Dose # 3
Submission of
antibody titres
showing immunity
is acceptable in
lieu of vaccines.
Please include
copy of lab results
showing immunity
Polio
Dates Polio
received:
Dose #1
Type:
Date:
Yellow Fever
Dose #1
Dose #2
Type:
Date:
Type:
Date:
Type:
Date:
Meningococcal
Conjugate
(MCV4)
Date(s) received:
Dose #2
Age when last
dose received:
Dose #3
Dose # 4
Dose # 5
Optional Vaccines given at
Hope College:
Not required: Please complete if you have already received
Hepatitis A
Hepatitis B
TB testing done at
Hope College
Type:
Date:
Result
Type:
Date:
Result:
Type:
Date:
Result:
INTERNATIONAL STUDENT HEALTH HISTORY FORM (continued)
PERSONAL & FAMILY HEALTH HISTORY
Height:
Mark all that apply:
Mark all that apply:
Weight:
Myself
Medication Allergies (list):
AutoImmune
Disorders:
Diabetes__________________________
Multiple Sclerosis__________________
Systemic Lupus____________________
Other:___________________________
___________________________________
Medications taken regularly:
Anemia__________________________
Clotting
Deficiency_______________________
Other:___________________________
__________________________________
Cancer
IN CASE OF EMERGENCY CONTACT
Specify:__________________________
___________________________________
NAME:_________________________________
Relationship:_____________________________
Phone # 1:_______________________________
Phone # 2:_______________________________
NAME:_________________________________
Relationship:_____________________________
Phone # 1:_______________________________
Phone # 2:_______________________________
Family
Digestive Disorders:
Crohn's Disease__________________
GERD__________________________
Irritable Bowel___________________
Peptic Ulcer_____________________
Other:__________________________
_________________________________
Eating Disorder:
Blood Disorders:
Hospitalizations/Surgeries:
Myself
Family
Cardio/Pulmonary
Disorders:
Asthma___________________________
Blood Clots_______________________
Heart Murmur______________________
Heart Disease_____________________
High Blood Pressure__________________
High Cholesterol___________________
Other:___________________________
__________________________________
Anorexia Nervosa________________
Binge Eating_____________________
Bulimia_________________________
Other:__________________________
_________________________________
Mental/Emotional
Disorders:
Anxiety_________________________
Depression______________________
Suicide Attempt__________________
Other:__________________________
_________________________________
Neurological
Disorders:
ADD/ADHD____________________
Cerebral Palsy___________________
Migraine Headaches________________
Seizures________________________
Other:__________________________
_________________________________
Other Immunization History - Indicate ONLY if already provided
BCG Vaccine
Hepatitis A
Typhoid
Yellow Fever
Name
Date:____________
Date:____________
Date:____________
Date:____________
Date:____________
Date:____________
Date:____________
Other (Specify):
Date
Date:____________
Date:____________
Date:____________
STATEMENT OF AUTHORIZATION
•
•
•
The information contained on this form is complete and I have not withheld any medical or mental health information. If any aspect of my
health profile changes after submitting this form, I will notify the Hope Health Center of this/these change(s) in writing.
I Authorize the Student Health Center of Hope College to administer medical and surgical services, including immunizations and to perform
routine and emergency diagnostic and therapeutic procedures as deemed necessary by duly licensed medical personnel. I understand that the
Medical Director, or designee, serves as primary physician for medical care provided by the Hope Student Health Center.
I understand that I will be required to undergo medical treatment for any current or future diagnosis of Latent Tuberculosis Infection (LTBI).
Failure to do so will result in withdrawal from current coursework and living arrangements at Hope College.
Signature of Student
Date