KIMBERLYTILLEY
Medical Director
Eric Cohen Student Health Center
Keck Medicine of USC
Dear New USC Health Science Campus Student,
I would like to extend a warm welcome and congratulate you on your admission to USC. Whether you are new
to USC or attended as an undergraduate, I would like to introduce you to the Eric Cohen Student Health Center
(ECSHC) of USC, your Medical Home on the USC Health Sciences Campus.
Please take the time to review this packet carefully and be sure you meet all of our health clearance
requirements. If you have any questions, please visit http://ecohenshc.usc.edu/health-clearance/ or
contact us via phone at 323-442-5980 or by email at [email protected].
The Eric Cohen Student Health Center is not a typical student health center. We are a small health center serving
only the graduate students on USC’s Health Sciences Campus. We offer comprehensive primary care as well as
a fully staffed counseling center on the premises. Before your first day of class, you can visit us for
immunizations, TB testing, and lab work only. You will be charged a $30 visit fee plus any charges associated
with the immunizations, TB or lab work received. Please visit http://ecohenshc.usc.edu/health-clearance/prices/
for price information. Once your classes begin, you will have access to all of the medical and counseling resources
at our health center. More information about our services can be found on our website https://ecohenshc.usc.edu/.
We are an accredited medical home clinic by the Accreditation Association of Ambulatory Health Care
(AAAHC), which means we offer the highest standards for patient care and patient experience. As your Medical
Home, we offer patient-centered care, with an emphasis on evidence-based medicine, personal attention, and
customer service. We hope you will use the clinic as your new primary care provider, not just when you are sick
or injured. We love to see our patients and get to know them and hope you will enjoy your experience with us.
Come by and visit us, we would love to see you.
Fight On!
Kimberly Tilley, MD
ECSHC Medical Director
Version B
HealthClearancePacket2017–VersionB
AllUSCHealthScienceCampusstudentsenteringintooneoftheclinicalprogramsbelowmustfilloutALLsectionsof
thispacketandsubmitwithaccompanyingdocumentationtoECSHCeitherbymailoremailbyJuly17,2017.
Program
PhysicalTherapy
Deadline
July17,2017
Program
Pharmacy
Deadline
July17,2017
Mail:
EricCohenStudentHealthCenterofUSC
Attn:HealthClearanceTeam
1510SanPabloSt.Suite104
LosAngeles,CA90033
Email:
To:[email protected]
Subject:AcademicProgram,StudentID#
Format:DocumentsmustbeinPDFFormat
Wedonotacceptfaxeddocument
FAQ:
1. Mydeadlinetosubmitmyhealthclearancepacketis[—–]butIamunabletomeetthatdeadline.CanIturninmy
paperworklater?
• Yes,youcan.However,ifyousubmityourpaperworkafterthedeadline,youmaynotbeclearedintimeforyour
programtoassignyoutorotateatyourclinicalfacilities.Pleasesubmityourpaperworkassoonaspossible.
2. Whatisatiter?
• Atiterisalaboratorytestthatmeasuresthepresenceandamountofantibodiesinblood.Atitermaybeusedto
proveimmunitytodisease.Abloodsampleistakenandtested.
3. Whatdoyoumeanby“attachfulllabresults”?
• Weneedalabreportwhichisgeneratedbythelabthattestedthebloodsample.Thereportmustincludethepatient
name,testname,testdate,exactvalues,andreferenceranges.Wewillnotacceptflowcharts.Pleaseseeexample:
4. Whatarethetestnumbersforthetiters?
•
•
•
•
•
MeaslesIgG(Quest#964,LabCorp#096560)
MumpsIgG(Quest#8624,LabCorp#096552)
RubellaIgG(Quest#802,LabCorp#006197)
VaricellaIgG(Quest#4439,LabCorp#096206)
HepatitisBSurfaceAntibodyQuantitativeOnly(Quest#8475,LabCorp#006530)
Website:ecohenshc.usc.edu|Phone:323–442–5980|Email:[email protected]
LastName:
DOB:
AcademicProgram:
CellPhone:
FirstName:
USCStudentID:
AnticipatedGraduationYear:
USCEmail:
A. MMR(Measles,Mumps,Rubella)-2dosesofMMRvaccineANDserologicproofofimmunityforMeasles,Mumpsand
Rubella
2dosesofMMRVaccine
Vaccine
MMRDose#1
Date
//
MMRDose#2
//
Measlespositiveserology
Test
SerologicImmunity(IgG,antibodies,titer)
Date
//
Mumpspositiveserology
SerologicImmunity(IgG,antibodies,titer)
//
Rubellapositiveserology
SerologicImmunity(IgG,antibodies,Titer)
//
Results(attachfulllabresults)
qPositive
qNegative
qPositive
qNegative
qPositive
qNegative
B. Varicella(ChickenPox)–2dosesofvaccineANDpositiveserology
Vaccine
Date
2dosesofVaricellaVaccine
VaricellaVaccine#1
//
VaricellaVaccine#2
//
Varicellapositiveserology
Test
SerologicImmunity(IgG,antibodies,titer)
Date
//
Results(attachfulllabresults)
qPositive
qNegative
C. HepatitisBVaccination–3dosesofvaccinefollowedbyaQUANTITATIVEHepatitisBSurfaceAntibody(titer)drawnat
rd
least30daysafter3 dose.Ifnegative,completeoneadditionalboostershotofHepatitisBVaccinefollowedbya
QUANTITATIVEHepatitisBSurfaceAntibody(titer)after30days.IfHepatitisBSurfaceAntibodyisnegativeaftersecond
QUANTITATIVEHepatitisBSurfaceAntibody,pleasecontacttheEricCohenStudentHealthCenterviaemail.
Vaccine/Test
Date
PrimaryHepatitisBSeries
HepatitisBVaccineDose#1
//
(Mustfilloutthissection)
HepatitisBVaccineDose#2
//
HepatitisBVaccineDose#3
//
Results(attachfulllabresults)
QUANTITATIVEHepBSurfaceAntibody
//
qPositive
qNegative
SecondaryHepatitisB
HepatitisBVaccineDose#4
//
(Filloutthissectioniffirst
Results(attachfulllabresults)
QuantitativeHepBSurface
QUANTITATIVEHepBSurfaceAntibody
//
qPositive
AntibodyisNegative)
qNegative
ChronicActiveHepatitisB
HepatitisBSurfaceAntigen
//
Results(attachfulllabresults)
(filloutonlyifapplicable)
HepatitisBViralLoad
//
qPositive
HepatitisBEAntigen
//
qNegative
D. Tetanus-diptheria-pertussis-One(1)doseofTdapfrom2006orlater.IfthelastTdapismorethan10yearsold,please
receiveanadditionalTDorTDAPvaccine.
Vaccine
TdapVaccine(Adacel,Boostrix,etcfrom2006orlater)
TdVaccine(ifmorethan10yearssincelastTdap)
Date
//
//
Website:ecohenshc.usc.edu|Phone:323–442–5980|Email:[email protected]
LastName:
DOB:
AcademicProgram:
CellPhone:
FirstName:
USCStudentID:
AnticipatedGraduationYear:
USCEmail:
E. TUBERCULOSISSCREENING:Pleaseanswerthequestionsbelow.Youranswerswilldeterminethetypeof
tuberculosistestyouneedtosubmit.
qYes qNo
1. HaveyoueverhadapositivePPD/TBskintest?
qYes qNo
2. HaveyoueverhadtheBCGvaccinefortuberculosis?*(seebelow)
qYes qNo
3. AreyouamemberofaTBhigh-riskgroup?**(seebelow)
qYes qNo
4. Haveyoueverbeentreatedfortuberculosis/receivedINHtreatment?
*BCG,orbacilleCalmette-Guerin,isavaccinefortuberculosis(TB)disease.Manyforeign-bornpersonshavebeenBCG-vaccinated.
BCGisusedinmanycountrieswithahighprevalenceofTBtopreventchildhoodtuberculousmeningitisandmiliarydisease(derived
fromtheCDC).
**YouareamemberofahighriskgroupifyouwereborninorresidedincountrieswhereTBisendemic.Itiseasiertoidentify
countriesoflowratherthanhighTBprevalence.Therefore,youarepartofahighriskgroupifyouwereborninorresidedincountries
EXCEPT:AMERICANSAMOA,AUSTRAILA,CANADA,BELGIUM,DENMARK,FINLAND,FRANCE,GERMANY,GREECE,ICELAND,IRELAND,
ITALY JAMAICA, LIECHTENSTEIN, LEUXEMBOURG, MALTA, MONACO, NETHERLANDS, NORWAY, SAN MARINO, SAINT KITTS AND
NEVIS,SAINTLUCIA,SWEDEN,SWITZERLAND,UNITEDKINGDOM,USA,VIRGINISALNDS(USA),orNEWZEALAND.Forexample,ifyou
werebornintheUSA,thenyouareNOTpartofaTBhigh-riskgroup.Youwouldanswer‘No’.
□
IfyouansweredYEStoQUESTIONS1or2or3,pleasesubmitaT.Spot.TB®ortheQuantiFERON®-TBGoldIGRAlab
testresultthatwastakenwithin3monthsofyouracademicstartdate(Fulllabresultsmustbesubmitted).
qTSPOT
TestDate://
qPositiveqNegative
qQUANTIFERON
□
If you answered YES to QUESTION 4, regardless of any other answer, please submit a chest x-ray report taken
within11monthsofyourprogramstartdateANDapastmedicalhistoryofyourpositivePPD.
TestDate://
Result:
□
IfyouansweredNOtoQUESTIONS1and2and3and4,youcaneither:
Option1 SubmitaT.Spot.TB®ortheQuantiFERON®-TBGoldIGRAlabtestresultthatwastakenwithin3monthsof
youracademicstartdate(Fulllabresultsmustbesubmitted).
qTSPOT
TestDate://
qPositiveqNegative
qQUANTIFERON
OR
Option2 Submitatwo-stepPPDSkintestwhereyourfirstTBskintestisplacedandreadanytimewithin11months
ofyourprogramstartdate(thisisPPD#1below)andyoursecondTBskintestisplacedandreadwithin3
monthsofyourprogramstartdate(thisisPPD#2below).
Atwo-stepPPDskintestistwoPPDtestsdonenosoonerthanoneweekapart.Thatmeansoneplacement&one
reading,thenatleastaoneweekwaitingperiod,thenanotherplacementandreading
PPD#1DatePlaced: //
PPD#1DateRead: //
Induration&Result:
PPD#2DatePlaced: //
PPD#2DateRead: //
Induration&Result:
Website:ecohenshc.usc.edu|Phone:323–442–5980|Email:[email protected]
LastName:
DOB:
AcademicProgram:
CellPhone:
FirstName:
USCStudentID:
AnticipatedGraduationYear:
USCEmail:
F.PHYSICALEXAM:TobeperformedbyanM.D.,P.A.,orN.P.
VITALS:B/P: __________Height _________Weight _________Pulse _________Resp._______ Temp.___________
Pleasecheckboxifpatientiswithinnormallimits.
GENERAL
HEENT
CHEST/LUNGS
CARDIOVASCULAR
ABDOMEN
MUSCULOSKELETAL
SKIN
NEUROLOGIC
MENTALSTATUS
qWNL
qWNL
qWNL
qWNL
qWNL
qWNL
qWNL
qWNL
qWNL
Anyrestrictionsonphysicalactivity?
qYes qNo
Anyrecommendationsformedicalcare?
qYes qNo
(Explainanyrestrictionsandrecommendations)
Ifpatientisnotwithinnormallimits,pleaseincludea
detaileddescriptionofanyabnormalfindings.
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
DateExamined________________________________
Address______________________________________
_____________________________________________
_____________________________________________
ProviderName________________________________
_________________________________________
_________________________________________
ProviderSignature_____________________________
_________________________________________
_________________________________________
Website:ecohenshc.usc.edu|Phone:323–442–5980|Email:[email protected]