GREENFIELD COMMUNITY COLLEGE
Health Records
One College Drive, Greenfield, Massachusetts 01301
TEL: (413) 775-1430 FAX: 775-1434
REQUIRED HEALTH INFORMATION
Documentation of immunity is required by the Massachusetts Department of Public Health and Greenfield Community
College for all full-time and all international students regardless of age. Include month, day and year of
immunization or blood test (titer). This form must be signed by a Health Care Provider. Students (all full-time
students, all full-time and part-time students on student visa including foreign students on exchange program), are
responsible for providing the Health Records Office with all required health information. This information must be
received no later than thirty days after the start of classes. Failure to do so will jeopardize your continued enrollment.
Please fill out this section completely.
Name
Last
First
Street
Apt.
City
State
Middle
Date of Birth
Address
Telephone (
Student Number or
Social Security Number
Zip Code
)
Area Code
GCC Major
Semester entering: Fall 20 ____
*
Spring 20 ____
Have you previously attended GCC? No ___
Yes ___ If yes, when: _______________
Previous Name(s)
Citizenship: US ____
Other ______________________
Specify Where
C:/Required Health Information Gen Student 3/8/11
* Health Occupation majors have different requirements and
students need to submit program specific health forms.
Return completed health forms to the Greenfield Community College Health Records Office.
Please call the Health Records Office if you have any questions concerning health requirements.
(OVER)
page 1 of 4
Student Name
Date of Birth _______ /______ /_______
Last
First
Middle
month
day
year
Social Security Number / Student ID Number:
Required
A.
Immunizations
Measles, Mumps, Rubella
Two doses of live measles, mumps and rubella vaccine
MMR #1 ____ /____ /____
MMR #2 ____ /____ /____
OR
Positive Measles (Rubeola) IgG Antibody ____ /____ /____ copy of lab report is required, please attach/enclose
Positive Mumps titer IgG Antibody ____ /____ /____ copy of lab report is required, please attach/enclose
Positive Rubella IgG Antibody ____ /____ /____ copy of lab report is required, please attach/enclose
OR
Born in the United States, before 1957 DOB ____ /____ /____
B.
Tetanus, Diphtheria, Pertussis
Tdap ____ /____ /____ (must have one) AND Td, IF Tdap is > 10 years old _____/_____/_____ Td
C.
Hepatitis B
Hepatitis B #1 ____ /____ /____
Hepatitis B #2 ____ /____ /____
Hepatitis B #3 ____ /____ /____
OR
Positive HBsAb ____ /____ /____  copy of lab report is required, please attach/enclose
D.
Varicella
Varicella Vaccine #1 ____ /____ /____ Varicella Vaccine #2 ____ /____ /____
OR
Positive VZ IgG Antibody ____ /____ /____  copy of lab report is required, please attach/enclose
OR
Reliable history of chickenpox disease signed by MD, NP or PA. Date of illness ____ /____ /____
OR
Born in the United States before 1980 DOB ____ /____ /____
Health Occupation students need to submit Program specific Health forms.
Health Care Pro vide r or Designee S ignature i s R equi r ed:
Signature
Printed Name
Address
Date
(
)
Telephone
C:/Required Health Information Gen Student September 2015
page2 of 4
GREENFIELD COMMUNITY COLLEGE
Health Services
One College Drive, Greenfield, Massachusetts 01301
TEL: (413) 775-1430 FAX: 775-1434
Tuberculosis Risk Questionnaire for Students
Name:
Birth date:
Last name, First name
Today’s date:
To the best of your knowledge, have you ever had close contact with anyone who was sick with Tuberculosis (TB)?
Were you born in one of the countries listed below?
Have you traveled or lived for more than one month in one of the countries listed below?
YES
NO






Countries with high rates of Tuberculosis (TB)*
Afghanistan
Angola
Armenia
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belarus
Benin
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Rep.
Chad
China
China, Hong Kong SAR
China, Macao SAR
Columbia
Comoros
Congo
Congo, DR
Cote d’Ivoire
Croatia
Djibouti
Dominican Rep.
Ecuador
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Gabon
Gambia
Georgia
Ghana
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran
Iraq
Kazakhstan
Kenya
Kiribati
Korea, DPR
Korea, Rep.
Kyrgyzstan
Lao PDR
Latvia
Lesotho
Liberia
Macedonia, TFYR
Madagascar
Malawi
Malaysia
Maldives
Mali
Marshall Islands
Mauritania
Mauritius
Micronesia
Moldova, Rep.
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nepal
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Northern Mariana Islands
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Portugal
Romania
Russian Federation
Rwanda
Sao Tome & Principe
Senegal
Sierra Leone
Solomon Islands
Somalia
South Africa
Sri Lanka
Sudan
Suriname
Swaziland
Syrian Arab Rep.
Tajikistan
Tanzania, UR
Thailand
Togo
Tokelau
Turkmenistan
Uganda
Ukraine
Uzbekistan
Vanuatu
Vietnam
Yemen
Zambia
Zimbabwe
*World Health Organization Global Tuberculosis Control, WHO report 2002
If the answer to any of the above questions is YES, the Massachusetts Department of Public Health strongly
recommends that you have a tuberculin skin test to check for latent tuberculosis infection. If the answer to all the
above questions is NO, a tuberculin skin test should not be done. Please note: If you have a positive tuberculin
skin test in the past, you do not need another test.
For Office use:
Mantoux recommended
 No
 Yes
page 3 of 4
 Medical Evaluation of College and University Students for Latent Tuberculosis Infection
Tuberculin Skin Test
Note: Use 5 TU Mantoux test (Intermediate PPD) only; result of multiple puncture tests, such as Tine or Mono-vacc, not accepted.
Date planted: _____/_____/_______
Date read: _____/_____/_______
mm of induration (If no induration, mark “0”)
Result:
(48 – 72 hours)
Risk-based Interpretation
(see box below)
 Negative
 Positive
Interpretation
of Tuberculin Test
Risk Factors for College Students
Positive Results
for College Students
without other risk factors
Close contact with a case of tuberculosis
5 mm or more
Born in a country that has a high rate of tuberculosis
10 mm or more
Traveled or lived for a month or more in a country that has a high rate of tuberculosis
10 mm or more
None [test not recommended]
15 mm or more
If the tuberculin skin test is positive a follow -up Chest X-ray is required:
Chest X-ray……….Date:
 Normal
 Abnormal:
(A copy of the x-ray report is required, please attach or forward.)
Describe
Clinical Evaluation……….Date:
 Normal
 Abnormal:
Describe
Treatment
 No
 Yes:
Drug, dose, frequency and dates
Health Care Provider Signature
Name
Address
Telephone
Required Health Information Gen Student September 2015
Page 4 of 4