Wilkes University Interna0onal TB Policy
Quan&FERON Gold is required for all NEW and con&nuing interna&onal students who have
exited the United States for more than 30 days, including:
• All incoming interna&onal students with an F-1 or J-1 visa.
• Con&nuing interna&onal students with an F-1 or J-1 visa who haven't been tested
• Con&nuing interna&onal students with an F-1 or J-1 visa who have leN the U.S. for more
than 30 days.
TB TESTING MUST BE DONE WITHIN 30 DAYS OF ARRIVAL TO THE UNITED STATES
Your results must be printed in English on official leRerhead of the medical provider who
performed the test. The document must be dated and include your name, date of birth and the
signature of the healthcare provider. You must you have the Quan&FERON TB Gold In-Tube test.
You must provide us with a printed copy of the test results.
If you had a chest x-ray performed as the result of a posi&ve TB test, we need a copy of the
wriRen chest x-ray report in English. The x-ray must be a two-view PA/Lateral.
If you are under the treatment for latent TB or ac&ve TB please bring documenta&on of your
treatment or past treatment including results. Bring any and all medica&on prescribed to you
by your physician.
A hold will be placed on your account and you will be unable to register for future classes un&l
you have the test done.
Results will NOT affect your visa or student status.
Students who have TB infec&on are not discriminated against in anyway. Wilkes University must
report cases of ac&ve TB (not inac&ve) to the county health department for inves&ga&on of
possible transmission to others. Otherwise, your health records are confiden&al and cannot be
released without your consent. Your TB test result will not appear on your academic documents.
For ques&ons or concerns contact:
Wilkes University Health and Wellness Services
Passan Hall 1st Floor
267 South Franklin Street
Wilkes-Barre, PA 18766
570-408-4730
[email protected] Physical Examination
This section is to be completed by physician/clinician.
__________________________________________________________________
LAST NAME (print) FIRST MIDDLE SEX
Blood Pressure_____/_____ Pulse_________ Height________Weight ________
SYSTEMS REVIEW
Normal Abnormal Describe
Abnormalities
Skin ________________ _______________ __________________
HEENT ________________ _______________ __________________
Lymph Nodes ________________ _______________ __________________
Neck ________________ _______________ __________________
Heart ________________ _______________ __________________
Lungs ________________ _______________ __________________
Back ________________ _______________ __________________
Breasts ________________ _______________ __________________
Abdomen ________________ _______________ __________________
Genitalia (Male) ________________ _______________ __________________
Pelvic (Female) ________________ _______________ __________________
Rectal ________________ _______________ __________________
Musculoskeletal ________________ _______________ __________________
Neuro/Psych ________________ _______________ __________________
Is the patient on any medications? Please list_______________________________
___________________________________________________________________
Does the patient have any known allergies? Please List ______________________
___________________________________________________________________
Recommendations for physical activity (college sports, PE, Intramurals, ROTC)
Unlimited_______________________ Limited_________________________
Explain:____________________________________________________________
Is this patient now under treatment for any medical condition?_________________
___________________________________________________________________
Is this patient now under treatment for any emotional condition?_________________
Do you have any recommendations regarding the care of this patient?_____________
____________________________________________________________________
HEALTH CARE PROVIDER
Print Name_____________________________Signature____________________________Date__________
Address_________________________________________________________________________________
Telephone:(____)-_______________________________Fax:(____)-____________________________
IMMUNIZATION RECORD
NAME_______________________________________________________________________________
Last First M.I.
Date of Birth_____________________________________ SS#__________________________________
Month/Day/Year
REQUIRED IMMUNIZATIONS
MUST BE UPDATED AS SPECIFIED BELOW
To be completed by a Health Care provider (Dates must include month and year.)
Tetanus Toxoid Diphtheria & Acellular Pertussis Vaccine (TDAP) (within 10 years) _________________________
Measles/Mumps/Rubella 1st dose____________________________2nd dose_______________________________
Mantoux test (within year) Date_____________________ Result_________________________________________
If Mantoux positive - chest X-ray results required
INTERNATIONAL STUDENT REQUIREMENT:
QuantiFERON Gold blood test Date_____________________ ___Result_________________________________
Must be done within 30 days of your arrival
If positive - chest X-ray with 2 views and a written x-ray result required in English
If you are an international student or have been out of the country for more than 30 days.
Please click here:
PA State law requires that college students be advised of the risks associated with meningococcal disease
and the availability/effectiveness of the vaccine www.cdc.gov/meningitis/index.html. All students living in
university owned housing must provide proof of vaccination or a written waiver before occupancy will be
permitted.
Two doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age,
with a booster dose at age 16. If the first dose (or series) is given between 13 and 15 years of age, the booster should be
given between 16 and 18. If the first dose (or series) is given after the 16th birthday, a booster is not needed.
Student will be living in university owned housing Yes______ No______
Meningococcal Vaccine Dose 1 ________________________Dose 2 _____________________
Student has been advised of the risks associated with meningococcal disease, the
availability/effectiveness of the vaccination and has decided not to receive the vaccination. At this time, the
student waives receipt of meningococcal vaccine.
Reason________________________________________________________________________________
Student Signature____________________________________________Date_______________________
HEALTH CARE PROVIDER
Print Name_____________________________Signature____________________________Date__________
Address_________________________________________________________________________________
Telephone:(____)-_______________________________Fax:(____)-____________________________
