MARIST
OFFICE OF ENROLLMENT SERVICES
(IN COORDINATION WITH THE
PHYSICIAN ASSISTANT PROGRAM)
HEALTH FORMS AND
IMMUNIZATION REQUIREMENTS
Congratulations on your acceptance to Marist College Physician Assistant Program!
Physician Assistant students are required to have a completed annual physical examination/medical attestation along with
titers for certain immunizations which will satisfy both admission requirements and most of requirements for your clinical
rotation year. The physical examination must be within one year of starting the program. A second physical exam must
be obtained prior to the clinical year. A copy of the laboratory report showing the positive numeric titer must also be
submitted. The physical examination details do not have to be submitted.
Carefully read all of the health packet documents. It is important to keep a photocopy for your records of all paperwork,
including lab results as they will need to be produced for rotation sites during the clinical year.
GUIDELINES:
• All forms with supporting documentation are due by April 15.
• You cannot matriculate into the program unless the information is received and is complete.
ENCLOSURES/FORMS:
• Immunization/Titer Requirements (with copies of labs showing numeric titers)
• Medical Attestation
• Tuberculosis Screening
• Proof of Influenza Vaccination
• Consent for Release of Confidential Health Information
• Health Insurance Information – Copy of Insurance Card
SUBMITTING YOUR INFORMATION:
• Please keep a copy of all health forms for your records.
• Please keep all of the forms together.
Marist College Office of Enrollment Services
Lowell Thomas 120
3399 North Road
Poughkeepsie, NY 12601
Please contact the Clinical Coordinator with any questions.
Thank you,
Gail Murphy, PA-C
Clinical Coordinator
Fax:
845-575-3215
Email:
Scan ALL completed documents to
immunization@marist.edu. Do NOT
send directly to Health Services.
MARIST
OFFICE OF ENROLLMENT SERVICES
(IN COORDINATION WITH THE
PHYSICIAN ASSISTANT PROGRAM)
IMMUNIZATION/TITER REQUIREMENTS
Must be completed by a health care provider
All titer results must be attached (numeric results)
A copy of immunization record with date, type and dose of immunizations (attached)
Measles – Titer results
OR if not immune, vaccine dates #1
#2
Mumps – Titer results
OR if not immune, vaccine dates #1
#2
OR if not immune, vaccine dates #1
#2
Rubella – Titer results
Varicella – Titer results
OR if not immune, vaccine dates #1
Hepatitis B - Titer results
1st Dose Date
#2
OR if not immune:
2nd Dose Date
3rd Dose Date
Or copy of signed declination
Hepatitis B antigen -
Tdap: date of last vaccination
(within 10 years)
Meningitis Immunization: I have (check on box and sign below):
□ had the meningococcal meningitis immunization with the past 10 years
Date Rec’d
□ read, or have had explained to me, the information regarding meningococcal disease. I understand the risks of not
receiving the vaccine.
Student Signature:
Date:
MARIST
OFFICE OF ENROLLMENT SERVICES
(IN COORDINATION WITH THE
PHYSICIAN ASSISTANT PROGRAM)
MEDICAL ATTESTATION
Student Name: Date of Birth:
I have evaluated the medical status of this individual and there are □ / are no □ medical conditions that would place
this individual at risk if he/she enters into the Marist College Physician Assistant Program. This individual has received
vaccinations/titers and does not have a health impairment that is a potential risk to patients or may interfere with the
performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or
other drugs or substances which may alter the individual’s behavior.
Signature of examining health care provider
Date
Print NameTelephone number
Address
MARIST
OFFICE OF ENROLLMENT SERVICES
(IN COORDINATION WITH THE
PHYSICIAN ASSISTANT PROGRAM)
TUBERCULOSIS SCREENING
Intradermal PPD Tuberculin Test: Annually updated and within one year of the start of the Program
Date Placed LOT#/Manufacturer
Placed by
Location of PPD
Date Read
Result in MM
Read by
If positive: Chest xray results:
date of Chest xray:
If applicable: TB GOLD date:
result:
Influenza – Required for current flu season (copy attached)
Date of vaccine:
(report attached)
MARIST
Student Name:
OFFICE OF ENROLLMENT SERVICES
(IN COORDINATION WITH THE
PHYSICIAN ASSISTANT PROGRAM)
CONSENT FOR RELEASE OF
CONFIDENTIAL HEALTH INFORMATION
Date:
I
, hereby authorize Marist College Office of Enrollment
Services to release my medical attestation, tuberculosis screening results, influenza vaccine documentation,
immunization/titer records and the copy of my health insurance card to the Marist College Physician Assistant Program.
I further authorize the Marist College Physician Assistant Program to release all or part of my medical attestation,
tuberculosis screening results, influenza vaccine documentation and immunization/titer records to the clinical sites to
which I am assigned. I understand that all other medical records will remain confidential and will not be accessible to or
reviewed by program faculty or staff.
Student Signature:
Date:
MARIST
OFFICE OF ENROLLMENT SERVICES
(IN COORDINATION WITH THE
PHYSICIAN ASSISTANT PROGRAM)
INSURANCE INFORMATION
Last Name: First Name: Middle Initial:
Date:
CWID#: Date of Birth:
Please copy the front of your health insurance card here
Please copy the back of your health insurance card here
I understand that I must maintain health insurance while enrolled in the Marist College Physician Assistant Program.
Student Signature:
Date: