2012 ― 2013 UCEAP ANNUAL HEALTH UPDATE UCEAP Country Specific Health Requirements QUESTIONS? About Country or Host Institution Specific Requirements, Deadlines, or Students, please call: Denmark, France, Germany, Italy, Netherlands, Russia, Sweden CONTACT PHONE E-MAIL Kitty Christen, International Program Specialist, Operations ........................... (805) 893-4430 (Denmark, Italy, Netherlands, Sweden) [email protected] Jill Harrison, International Program Specialist, Operations ..................... (805) 893-4255 (France, Germany, Russia) [email protected] Botswana, China, Ghana, Hong Kong, Japan, Korea, Singapore, South Africa, Taiwan, Tanzania, Thailand, Vietnam May Pothongsunun, International Program Specialist, Operations…..…(805) 893-6152 (China, Hong Kong, Singapore, Thailand, Vietnam) [email protected] Amy Frohlich, International Program Specialist, Operations................... (805) 893-2831 [email protected] (Botswana, Ghana, Japan, Korea, Senegal, South Africa, Taiwan, Tanzania) On leave until 2/6/12 Michelle Hertig, International Program Specialist, Operations …………(805) 893-2831 [email protected] (Botswana, Ghana, Japan, Korea, Senegal, South Africa, Taiwan, Tanzania) Until 2/6/12 Australia, Barbados, Canada, Egypt, India, Ireland, Israel, New Zealand, Turkey, United Kingdom Jeanie O’Connell, International Program Specialist, Operations ............ (805) 893-5926 (Australia, Barbados, Canada, India, New Zealand) [email protected] Michelle Bobro, International Program Specialist, Operations................ (805) 893-3246 (Egypt, Ireland, Israel, Turkey, United Kingdom) [email protected] Argentina, Brazil, Chile, Costa Rica, Mexico, Spain Stacey Lydon, International Program Specialist, Operations .................. (805) 893-4268 (Costa Rica, Spain) [email protected] Kristen Galbreath, International Program Specialist, Operations ...... (805) 893-4138 (Argentina, Brazil, Chile, Mexico) [email protected] About EAP Health Clearance and Student Medical Cases, please call: Inés DeRomaña, Principal Analyst December 2010 (805) 893-7936 [email protected] 6950 Hollister Avenue, Suite 200 Goleta, CA 93117-5823 JANUARY 2012—SUPERSEDES ALL PRIOR UPDATES Annual Update of UCEAP Country-Specific Requirements To: Campus Student Health Services and Campus EAP Offices From: University of California, Education Abroad Program (UCEAP) Systemwide Office Re: 2012–2013 Medical Requirements and Recommendations and the UCEAP Health Clearance Process Many UCEAP participants will make appointments for their required UCEAP through campus Student Health Centers. Please read all information below. REQUIRED UCEAP CONFIDENTIAL HEA LTH HISTORY FORM (See Appendix) Students must complete the C ON FID E NT IA L Review it carefully with them. H E A L T H H I S TO R Y form before their health consultation. Keep a COPY for your files, and return a COPY to the student. Advise students to bring a copy of the form abroad in case of an emergency. REQUIRED UCEAP HEALTH CLEARANCE FORM (See Appendi x) Read instructions carefully before completing the form. The University of California desires a solid and safe transition of care for those students who are currently in treatment. Complete the UCEAP Health Clearance form accurately and legibly to prevent delays with the student’s participation in UCEAP; incomplete forms may be returned. All copies must be legible. The student must return a copy to the UCEAP Systemwide Office no later than 60 days before his/her departure (except for Chile). IMPORTANT: If a specialist or specialists is/are currently seeing the student for an ongoing medical or psychiatric condition, each specialist must also clear the student and sign the form with detailed contact information. Do not return the forms without the signatures of all required parties (specialists, health practitioners, etc.) as this will delay the student’s participation. We regularly manage student emergencies while abroad so we are aware that some students decompensate while on UCEAP—some requiring hospitalization care and others who did not. Be aware that many students do not follow up adequate health management while on UCEAP. UCEAP 2012 Annual Health Update 1 of 19 REQUIRED UCEAP ONLINE TRAVEL HEALTH EDUCATION CERTIFICAT IO N COURSE (See Appendix) The following countries require travel medicine certification: Argentina, Barbados, Botswana, Brazil, China, Egypt, Ghana, India, Mexico, Russia, South Africa, Tanzania, Thailand, Turkey, and Vietnam. REQUIRED COUNTRY AND/OR HOST UNIVERSITY SPECIFIC FORMS (See Appendi x) Forms provided in the Appendix section are SAMPLES only. All students have received specific instructions and updated forms for their programs from the UCEAP Systemwide Office in their predeparture checklists. ALCOHOL AND DRUGS WH ILE ABROAD IMPORTANT: Alcohol poisoning and drug use have impacted UCEAP students in many ways. Excessive alcohol consumption and unruly behavior has led to serious problems with local law officials. Ask students directly about their alcohol and/or drug consumption patterns to detect atrisk or problem drinkers so you can advise them appropriately. UCEAP follows University of California substance abuse policies while students are abroad. Students who violate UCEAP’s substance abuse policy while abroad may be dismissed. While abroad, students are subject to the laws of their host country regarding alcohol consumption, illegal drugs, and other substances. In some countries, alcohol is limited or outlawed because of religious practices. In other countries, alcohol will be readily available locally, and the alcohol content will probably be higher than in the U.S. The related risks posed by excessive drinking and intoxication are as present in education abroad programs as they are on UC campuses. While it may be common for college students to responsibly drink all over the world, Help us educate students about the following: Drinking responsibly or not at all. Remind students that drinking can lead to potentially harmful situations such as unsafe sex, sexual assault, theft, and physical attacks or fights. Higher alcohol content in drinks can also increase the risk of alcohol poisoning. Warn students that some countries are not as tolerant of drinking, that public drunkenness is unacceptable and illegal, and that the dangers of drinking too much are the same anywhere students go. Notify students that the importation, purchase, possession, or use of drugs in some countries can incur severe penalties, including imprisonment without bail for up to a year before a case is tried, and imprisonment of several years following a conviction. ADDITIONAL MEDICAL TESTS AND/OR SPECIAL COUNTRY RECOMMENDATIONS In addition to the mandatory UCEAP health clearance, some programs require medical tests and/or have special recommendations. o Give the results of the medical tests to the individual students for their personal use in obtaining visas and university registration. Please refer to this document and e-mail updates during the year for the most recent information. UCEAP 2012 Annual Health Update 2 of 19 UCEAP RECOMMENDED VACCINES Fall/Winter Programs Seasonal Flu Vaccine: Dr. Mark Hansen, UCSB and UCEAP Physician Consultant, strongly recommends a flu vaccine for any student with chronic medical conditions; all other students should consider it. Influenza is one of the most common ailments that UCEAP students report. Students may travel in crowded vehicles and visit crowded places—both situations that promote transmission. All students planning to live in dormitories should have at least one Meningococcal vaccination (called Menactra or Menveo). Students who received this shot before age 16 should receive a booster dose. CURRENT OUTBREAK OF MEASLES – January 2012 According to CDC, Europe, Africa and the Americas are currently experiencing an outbreak of Measles. Refer to CDC travel notice, here http://wwwnc.cdc.gov/travel/notices/in-the-news/measles.htm. All travelers should have previously received 2 doses of the vaccine MMR. STUDENTS USING MEDIC ATION Some countries do not honor U.S. prescriptions abroad. A medical identification bracelet or disk is recommended for students with specific medical conditions; drug, insect, or food/drug allergies; and/or prescribed medicines. Any student who uses medication, including asthma inhalers and oral contraceptives, on a regular basis should bring with them a supply sufficient to last throughout their stay. Such individuals should carry a letter from their physician explaining the medical problem and treatment. MEDICATION MANAGEMENT Students must take sufficient medication to last for the duration of UCEAP but only if the medication can legally be brought into the country. Student must make sure, before departure, that the medication is locally available or that there is an appropriate substitute, if not locally available. Students can contact Europ Assistance (EA) for advice about traveling with specific prescriptions to their UCEAP destination. Email: OPS@europassistance‐usa.com. Telephone: 1+ (866) 451‐7606. Students must provide the UCEAP policy number (#ADDN04834823) and their country of destination for EA to determine whether prescription is legal. In some countries, drugs that are legal and readily available in the United States will be considered illegal, require a prescription, or arouse the suspicions of local officials and customs and immigration authorities. Advise students to take appropriate precautions when traveling with such supplies. Students who are being treated for a psychological health condition should work closely with their physicians about medication management, what side effects to watch for while abroad and whether their prescription is available overseas (for example, Adderall is not legal in France, India, etc.). As you are aware, all too often, students feel better after being on medication for three or four months so they stop taking it while abroad without consulting with a doctor. Unfortunately, symptoms frequently return a few weeks later. Advise students that compliance with medication regimens, as prescribed, is important and to never abruptly discontinue their medication. UCEAP 2012 Annual Health Update 3 of 19 MAILING MEDICATION ABROAD Most countries have strict rules regulating medications shipped abroad. Some students find that refills of regularly taken medications in the U.S. get stopped by the host country's customs officials. Decisions on what medications may be mailed legally into some foreign countries are made by the host country government, not the U.S. Post Office. Students should call the UCEAP travel assistance provider, Europ Assistance, at (866) 451-7606 or e-mail [email protected]. For example, due to strict and different regulations regarding pharmaceuticals (for example, some vitamins are considered drugs) the German Consulate General in the U.S. advises against mailing medications into Germany. Most pharmaceuticals are obtainable in international pharmacies in Germany with the respective doctor's prescription. Other countries have similar restrictions. PSYCHOLOGICAL HEALTH During the health clearance, pay special attention to any emotional or psychological problems and any medications the student is taking. Many experienced education abroad administrators and advisors view the possibility of known, or new, emotional and mental problems emerging overseas as a health and safety concern second only to alcohol abuse in its potential negative impact on an education abroad experience. Like substance abuse, its primary impact may be on the well-being of one person, but its side effects can carry over to others—even an entire group. Preexisting emotional difficulties are often intensified by living in a foreign culture. Students (along with their parent/guardian and physician) are responsible for assessing any physical or psychological health conditions that may be adversely affected by studying abroad. Not all countries have mental health support services or treatment facilities similar to those in the U.S. UCEAP strongly encourages you to discuss with students who are in need of continued therapy, monitoring, or specific support mechanisms while abroad that their condition may become exacerbated once abroad. Advise students to communicate with UCEAP before departure so UCEAP can work with the student to arrange appropriate accommodations abroad, when possible. NOTE: All information that the student relates to UCEAP will be kept completely confidential. STUDENTS WITH DISABILITIES Advise students to take a copy of the medical documentation with them, along with a copy of the campus disability office letter. Some host institutions will require medical documentation directly from the student to provide specific accommodations. UCEAP 2012 Annual Health Update 4 of 19 UCEAP Health Clearance Instructions for Students All students are required to obtain a health clearance to participate in EAP. Students who do not comply with this requirement may be dismissed. You are responsible for following stipulated deadlines. The health clearance must be completed no later than two months (60 days) before departure. (If you will be studying in Chile, see below.) HEALTH CLEARANCE REQUIRED FROM CAMPUS STUDENT HEALTH SERVICE Botswana Ghana India Senegal South Africa Tanzania INSTRUCTIONS Obtain a health clearance from the campus Student Health Service (SHS). The campus EAP office has specific instructions. Since appointments must be made with the campus SHS, begin this process immediately. HEALTH CLEARANCE REQUIRED FROM CAMPUS SHS – OR – PRIVATE PHYSICIAN* Argentina Australia Barbados Brazil Canada China Costa Rica Denmark Egypt France Germany Chile Hong Kong Hungary Ireland Israel Italy Japan Korea Mexico Netherlands New Zealand Russia Singapore Spain Sweden Taiwan Thailand Turkey United Kingdom Vietnam INSTRUCTIONS You may obtain a health clearance either from the campus Student Health Service (SHS) or from a private physician. If you choose to use the campus SHS, follow all instructions provided by the campus EAP office. If you decide to use a private physician, you must follow instructions 1–4 below. It is your responsibility to complete the process by stipulated deadlines, but no later than two months before departure. INSTRUCTIONS You may obtain the health clearance either from the campus Student Health Service (SHS) or from a private physician. If you choose to use the campus SHS, you should follow the instructions provided by the campus EAP office. The Chilean Consulate General requires that health clearances be completed and dated 30 days, or less, before you apply for your student visa. The Chilean consulate will not process your student visa if the health form is not dated as required. For example, if you apply for a visa on July 1, the health clearance form cannot be dated before June 1; i.e., the date on the Health Clearance form needs to be any day between June 1 and June 30. ONLINE TRAVEL HEALTH EDUCATION CERTIFICATION COURSE Argentina Barbados Botswana Brazil China Egypt Ghana India Mexico Russia Senegal South Africa Tanzania Thailand Turkey Vietnam INSTRUCTIONS This course does not replace an in-person appointment with a travel health provider for necessary medications and immunizations. You are required to complete the UCEAP Travel Health Education course https://myeap.eap.ucop.edu/travelhealth/ie7/index.html?dhtmlActivation=inplace and submit the Certificate of Completion form to the UCEAP Systemwide Office by the designated deadline. After you complete the course, you must make an appointment with a travel health provider (at your campus Student Health Center OR a private travel clinic specialist) immediately. It is critical to consider vaccine-preventable diseases that may be easily caught during travel, especially if you have a preexisting medical condition. INSTRUCTIONS FOR STUDENTS RECEIVING A HEALTH CLEARANCE FROM A PRIVATE PHYSICIAN 1. Depending on your campus instructions, get the Confidential Health History form from the campus EAP office, or SHS. a. Complete the form clearly and accurately before seeing the doctor. b. SIGN the form. 2. Depending on your campus instructions, get the UCEAP Health Clearance form from the campus EAP office, or SHS. a. Follow detailed instructions on the form. b. Do not forget to complete the form with your name and program information. 3. Make an appointment with your personal doctor (if your UCEAP destination allows clearances from outside practitioners), and any specialist you may be seeing for an ongoing condition. a. Take the completed Confidential Health History and Health Clearance forms to the appointment. b. Ask the physician to follow the instructions on the UCEAP Health Clearance form carefully. IMPORTANT: The physician/health provider/specialist performing and signing the clearance must be licensed and cannot be an immediate family member (AMA Code of Ethics E-8.19). AFTER THE HEALTH CLEARANCE APPOINTMENT Depending on your campus instructions, after the appointment send the completed, signed original and a copy of the UCEAP Health Clearance form* to: University of California Education Abroad Program, Systemwide Office 6950 Hollister Avenue, Suite 200 Goleta, CA 93117-5823 UCEAP must receive this form at least two months* (60 days) before departure so you can participate in EAP*. * Except Chile: The General Consulate of Chile requires that health clearances be completed and dated 30 days, or less, before you apply for the student visa. Keep the original of the Health Clearance form for the student visa application. For more information refer to the Pre-Departure Checklist; you will receive an e-mail when it is available online. Revised: January 2012 Page 2 of 3 CONFIDENTIAL HEALTH HISTORY FORM - Do not send a copy to the UCEAP Systemwide Office. 1. Leave a copy of the Confidential Health History form with your doctor so that it will be on file in case of an emergency. 2. Keep a copy with your passport in case of a medical emergency while on UCEAP. You can also ask the UCEAP Study Center to keep a copy in case of a medical emergency. Do not send a copy to the UCEAP Systemwide Office. UCEAP ONLINE TRAVEL HEALTH EDUCATION CERTIFICATION COURSE Depending on your campus, after you successfully complete the online health education course, print a copy of your certificate of completion and schedule an appointment with a travel clinic specialist. STUDENTS WITH SPECIAL NEEDS: If you have any disability, or other chronic systemic condition for which you will be seeking accommodation abroad, you must advise the Campus EAP office immediately so staff can notify the EAP Systemwide Office (UCEAP); you may have your UC campus Disabled Students Office send a memo to UCEAP indicating the nature of your needs. In light of varying circumstances at sites abroad, universities abroad will require this memo with sufficient notice for a request for accommodations to be fairly evaluated. The students must secure funding. Students who disclose needs at the last minute, or who require accommodations that cannot be made available in the host country, may be advised to postpone participation or consider another site. (DB 8/11/03) Revised: January 2012 Page 3 of 3 COUNTRY AND HOST UNIVERSITY HEALTH REQUIREMENTS Argentina Germany Russia Australia Ghana Senegal Barbados Hong Kong (S.A.R.) Singapore Botswana India South Africa Brazil Ireland, Republic of Spain Canada Israel Sweden Chile Italy Taiwan China Japan Tanzania Costa Rica Korea, South Thailand Denmark Mexico Turkey Egypt Netherlands United Kingdom France New Zealand Vietnam UCEAP 2012 Annual Health Update 5 of 19 ARGENTINA Required by Government: -0Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) AUSTRALIA Required by Government: When applying for the mandatory student visa—an electronic application process—some students, depending on their length of stay and other factors, will be required by the Australian Department of Immigration to undergo a medical exam and chest X-ray. In such cases, the Australian embassy will give students instructions to download the specific and required medical forms needed for submission. Students must have these forms completed by a physician and returned to the Australian embassy in Washington, D.C. Required by Host University: -0BARBADOS Required by Government: Yellow fever, if traveling from endemic zone Required by Host University: University of the West Indies Confidential Medical Questionnaire (see Appendix) Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) BOTSWANA Required by Government: Yellow fever, if traveling from endemic zone Required by CIEE: Anti-malarial medication for the required program excursion to northern Botswana, such as the Okavango Delta. This medication must be purchased before leaving the U.S. If filled and paid for within 14 days before the official start of the program, the prescribed antimalarials are covered by UCEAP insurance. Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) UCEAP 2012 Annual Health Update 6 of 19 BRAZIL Required by Government: Yellow fever, if traveling from endemic zone Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: Cholera is present. Students must make sure that food and drinking water are safe. Discuss protective measures against insect bites with students. CANADA Required by Government: -0Required by Host University: -0CHILE Chile has two consulates in California, located in San Francisco and Los Angeles. Where a student goes to apply for their visa is determined by their permanent home address, not necessarily their UC campus. The consulates have different requirements. The General Consulate of Chile in Los Angeles requires that health clearances be completed 30 days, or fewer, before a student applies for the student visa. In other words, if a student completes the clearance more than 30 days before their visa application, the clearance essentially “expires” and the student has to complete a new one. The General Consulate of Chile in San Francisco requires that health clearances be completed within six months of the visa application. Despite this flexibility, UCEAP recommends that the clearances be done within three months of the visa appointment. Both Chilean consulates require an MD signature on all health clearances (whether an FNP, NP, or PA performs the clearance). The doctor's name and title must be clearly and carefully printed, and all contact information must be included. In addition, all health clearance forms must have an SHS/University of California stamp or the private physician’s stamp (validation stamp and business card). Forms that do not conform to this requirement will be returned, which will delay the student’s visa process. Required by Host University: -0Required by Government: To get a student visa for Chile, a student must present the following to the Chilean consulate: 1. The original of UC’s Health Clearance form signed by a medical doctor 2. An official HIV test certificate (ONLY for students getting their visa through the SF Consulate) Required by Host University: -0IMPORTANT HEALTH ADVICE: Severe air pollution exists in Santiago, especially during the winter months of May through August. Air pollution occurs to a lesser extent in the Chilean countryside. Students with emphysema, asthma, and bronchitis should expect an increase in respiratory symptoms. UCEAP 2012 Annual Health Update 7 of 19 CHINA, PRC Required for all programs in China by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) Beijing Normal University Summer Program East China Normal University Summer Program Fudan University Fall or Spring terms Peking University Spring Program Tsinghua University Spring Program Required by Government: Yellow fever vaccine if traveling from endemic zones Required by Host University: -0Beijing Normal University Fall and Peking University Year Required by Government: Yellow fever vaccine if traveling from endemic zones All tests indicated on the Foreigner Physical Examination Form (health exam from Beijing Health and Quarantine Bureau of P.R., China). Instructions below. (See Appendix.) o Tests should be completed in the U.S. no more than six months before the student’s departure date for China; otherwise, it will be considered invalid. FOREIGNER PHYSICAL EXAMINATION FORM - INSTRUCTIONS: The two-page Foreigner Physical Examination Form is required for students studying in China for more than six months. A sample form is included for reference purposes only. Students should use the form provided by UCEAP on their Pre-Departure Checklist. Complete all boxes; do not leave any section blank. o If test results are negative, write “negative.” All original lab exam results attached to the form must be specific. TB test must be performed and findings attached to the health form. o A positive TB skin test requires negative chest X-ray results. o Original chest X-ray films are not required, but a printed report is required. o Students with active TB will not be allowed into China. On page 2, the box next to “Chest X-ray exam” must be marked with results; the original report is required (original X-ray films are not required). On page 2, the box next to “ECG” must be marked with results; the original printout results are needed. The Chinese government will not accept a photocopy of the HIV test result. o Do not submit test results marked “copy.” o Original results are required. On page 2, the box next to “Laboratory exam” must be marked with the test results. oThe original blood test reports must be included for both AIDS and syphilis. UCEAP 2012 Annual Health Update 8 of 19 CHINA, PRC - continued o If test results are not clearly marked as negative, students may be required to undergo a duplicate health exam in China. On page 2, each disease in the section “None of the following diseases or disorders found during the present examination” should indicate the results by the attending physician. An official stamp from the SHS or the private physician is required on both pages: on the student’s photo on page 1 and next to the physician’s signature on page 2. This can be an address stamp, if no other stamp is available. What happens with the Foreigner Physical Examination Form once it is completed? The medical form required for participants is primarily a governmental requirement and secondarily host university requirement. Following is an explanation of how the process works, and what will be required to receive proper student visa materials from the host universities in China. Fall BNU and PKU year students must have the completed paperwork and original test results for their visa application and for host university registration. o Students may have to repeat some tests in China after arrival if all test results are not given to students or if test results are unclear. Fall BNU and PKU year students must complete a special physical exam and the required lab work at their campus Student Health Service (SHS) in coordination with the UCEAP Confidential Health History and the Health Clearance forms. o If you have questions about whether or not a particular student needs to complete the Chinese health form, call the UCEAP Operations Specialist May Pothongsunun at (805) 893-6152. Students must make a copy of the fully stamped forms and submit it with their visa application. They will not give the originals to the Chinese Consulate before departure. They must keep the originals for processing their residence permits in China. Students must bring all originals with them to China. If they do not have their health forms, they will have to repeat the tests again in China at their own expense. IMPORTANT HEALTH ADVICE: Air pollution is bad in Beijing. Recommend that students with asthma or other respiratory ailments consult their physician for recommendations. COSTA RICA Tropical Biology Programs (Monteverde Fall and Spring) Important information about the program: Students will be spending at least 10 weeks in tropical rain forest, dry forest, and coastal areas. The program includes strenuous outdoor activities. Students with emotional or psychological issues have extreme difficulty on this field program. The academic work is demanding and there are several field trips; students are always together in a group. UCEAP 2012 Annual Health Update 9 of 19 COSTA RICA - continued There is little privacy; group dynamics are extremely important and students must be able to manage well in group situations. Students must be prepared mentally as well as physically for a fairly stressful 10 weeks. Although reliable medical services are available throughout Costa Rica and its outlying provinces, students will be living in a rural tropical environment. There is a clinic in Santa Elena, about four kilometers from Monteverde that can handle uncomplicated medical needs. It does not have extensive lab facilities. It is staffed with doctors, nurses, and a dentist. The clinic includes a pharmacy. The nearest hospital is two hours from Monteverde in Puntarenas. Required by Government: -0Required by Host University: -0IMPORTANT HEALTH ADVICE: Students must make sure that food and drinking water are safe. DENMARK Required by Government: -0Required by Host University: -0EGYPT Required by Government: HIV test will be given by the Egyptian Ministry of Health within one to three months after arrival in Egypt. Cholera vaccination required only if coming from a country with an outbreak of cholera. International Certificate of Vaccination for yellow fever required only if arriving from a country any part of which is considered an endemic zone. (See the yellow fever endemic zone map on the CDC website) Required by Host University: Students must have a full physical examination plus an HIV test. The AUC Physical Examination Record must be completed, with lab test results attached. Final registration at the host university is dependent upon a physical examination and a negative HIV test. The physician should mail the completed form directly to the address on the form and give a copy to the student (see Appendix). Required by UCEAP and the UCEAP Physician Consultant for all programs in Egypt: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) UCEAP 2012 Annual Health Update 10 of 19 FRANCE Required by Government: A medical exam is given after arrival in France for the purpose of the residence permit for students with semester- or year-long visas. The exam is non-invasive (no blood work) but includes an X-ray to screen for TB. GERMANY Required by Government: -0Required by Host University: -0GHANA IMPORTANT HEALTH ADVICE: Medical facilities in Ghana are limited or nonexistent, particularly outside Accra, the capital. Serious medical problems will require air evacuation to a country with state-of-the-art medical facilities. Recommend that students carry a supply of any needed prescription medicines, along with copies of the prescriptions, including the generic name for the drugs, and a supply of preferred over-thecounter medications. Students must receive information on vaccinations and other specific health precautions, such as safe food and water precautions and insect bite protection. UCEAP students have become seriously ill with malaria due to ineffective adherence to anti-malarial pills and lack of follow-up with effective personal protective measures. Medical supplies and staff are limited. As water and electricity supply in Accra are erratic, health facilities are directly affected by shortages of electricity, which render equipment nonfunctional and make it difficult to keep vaccines, samples, and medications at the appropriate temperature. The role of family and friends is stronger and depended upon in the hospital system. For example, bringing meals and comfort items such as fresh water and clean clothes is considered the role of the family and friends. Students need to be prepared for the inevitable cultural differences in medical services. Students who need a particular type of medical care should find out in advance whether such care is available. Laws governing availability of medications vary widely. Prescription medications are often not available in the needed formulations or strengths. Students may want to consider bringing a supply sufficient for their stay abroad. Required by Government: Immunization for yellow fever is required upon arrival from all countries, to be noted on the International Certificate of Vaccination (ICV). The certificate should be affixed to the visa inside of the student’s passport and presented at the port of entry in Ghana. Required by Host University: Malaria prophylactic pills—all students going to University of Ghana sign a Malaria Prophylaxis Participation Agreement (see Appendix) UCEAP 2012 Annual Health Update 11 of 19 GHANA – continue d Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) Malaria: According to CDC, students should purchase their antimalarial drugs before travel. Drugs purchased overseas may not be manufactured according to United States standards and may not be effective. They also may be dangerous, contain counterfeit medications or contaminants, or be combinations of drugs that are not safe to use. The UCEAP insurance covers anti-malarial prescription medication if filled and paid for within 14 days before the official start of the UCEAP program. Malaria has been a major, serious, and dangerous health problem for students who stop taking their malaria prophylactic pills in Ghana. Help students to understand that they must protect themselves from malaria by taking an antimalarial drug and by preventing mosquito bites. For more information when advising students, CDC Malaria Hotline: (770) 488-7788 or (855) 856-4713 toll-free (M-F, 9am-5pm, eastern time) Cholera could be present, but vaccination offers only brief, incomplete protection. Students must make sure that food and drinking water are safe. Student must be advised to wash hands frequently. Tuberculosis is a significant health problem. Travelers planning an extended stay should have a predeparture TB skin test (PPD test) and be re-tested after leaving this country. HONG KONG Required by Government: -0Required by Host University: Although CUHK has a health form for students to complete before departure, there are no special medical tests or physician signatures required. A sample form is included for reference only (see Appendix). CUHK will include the form as part of their admission packet. HKU, HKUST and HK Poly U have no university health forms. INDIA Required by Government: International Certificate of Vaccination for yellow fever is required upon arrival for any traveler coming from a country any part of which is infected and who is more than 1 year of age. Required by IES for UC Explores New Delhi: IES Medical Report – two parts (see Appendix). Required by the Alliance for Contemporary India: Development, Environment, Public Health, Pune: Medical Report (see Appendix). Required by CIEE for Univ. of Hyderabad: -0- UCEAP 2012 Annual Health Update 12 of 19 INDIA – continued Required by UCEAP and the UCEAP Physician Consultant for all programs in India: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: Advise students to take adequate supply of prescription medication and to check with Europ Assistance (see page #3 for contact information) whether a medication is legal (e.g., Adderall is illegal and cannot be brought into the country.) Advise on protective measures against insect bites. IRELAND Required by Government: -0Required by Host University: -0ISRAEL Required by Government: -0Required by Host University: Complete physical examination including urinalysis. Hebrew University Report of Medical Examination must be completed and results of any lab work noted on the form (see Appendix). ITALY Required by Government: -0Required by Host University: -0- JAPAN Required by Government: -0Required by Host University: Certain host universities require a health form (see Appendix). All tests must be done within three months of application All tests mentioned on the forms are required, unless deleted on sample form that is provided in the Appendix of this publication. UCEAP 2012 Annual Health Update 13 of 19 JAPAN - continued Japanese health form required for: Japanese health form not required: • Hitotsubashi University • Doshisha University • International Christian University (ICU) • Meiji Gakuin University • Keio University • Osaka University • University of Tokyo • Tsukuba University • Tohoku University • Tsuru University • Waseda University IMPORTANT: Medication U.S. prescriptions are not honored in Japan, so travelers with ongoing prescription medicine needs should arrive with a supply that will last through their stay in Japan, or enough until they are able to see a local care provider. Certain medications, including some commonly prescribed for depression and attention deficient disorder (ADD), are not widely available. It is illegal to bring into Japan some over-the-counter medicines commonly used in the United States, including inhalers and some allergy and sinus medications. Specifically, products that contain stimulants (medicines that contain pseudoephedrine, such as Actifed, Sudafed, and Vicks inhalers) or codeine are prohibited. Up to a two-month supply of allowable over-thecounter medication and up to a four-month supply of allowable vitamins can be brought into Japan dutyfree. Some U.S. prescription medications cannot be imported into Japan, even when accompanied by a customs declaration and a copy of the prescription. Generally, up to a one-month supply of allowable prescription medicine can be brought into Japan. Travelers must bring a copy of their doctor's prescription as well as a letter stating the purpose of the drug. Japanese physicians can often prescribe similar, but not identical, substitutes to medicines available in the U.S. KOREA, SOUTH Required by Government: -0Required by Host University: -0Required by Host University Housing Department: TB test results medical report. Students must submit the test results upon arrival at the on campus housing. There is no actual form. MEXICO Required by Government: Statement of good health to be provided by the SHS or the examining physician: This can be a photocopy of the UCEAP Health Clearance form, or a letter stating that the student is in good health. Required by Host University: -0- UCEAP 2012 Annual Health Update 14 of 19 MEXICO - continued Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: Environmental Pollution: Acute respiratory infections are a common cause of illness in Mexico and are aggravated by Mexico’s air pollution—the worst in the world. Extreme conditions can occur in Mexico City and Guadalajara, especially from December to May. NETHERLANDS Required by Government: -0- Required by Host University: -0- NEW ZEALAND Required by Government: -0- Required by Host University: -0- RUSSIA Required by Government: To get a student visa for Russia, students must submit an HIV/AIDS test along with their visa application to Travisa, a visa processing company. Students have received instructions on how to proceed. The results of this test must be printed on a form that clearly states the student’s name as shown on the passport. No official form exists. Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: Cholera is present, but the risk to students is low. Students must be advised to wash hands frequently and observe water and food precautions. HIV/AIDS is prevalent and travelers are cautioned against unsafe sex, unsterile medical or dental injections, shared needles, and unnecessary blood transfusions. SENEGAL IMPORTANT INFORMATION ABOUT SENEGAL Peanuts are the main crop of Senegal and everywhere the aroma of roasted peanuts permeates the air. So peanuts are practically unavoidable in Senegal and the majority of dishes contain some form of peanuts. The program organizers, CIEE, will require a doctor’s note from any students with peanut allergies so they can better understand the severity of the condition. According to staff at CIEE, students whose allergies are severe enough to induce anaphylaxis should consider another program. CIEE staff explain this as clearly as possible so students understand the seriousness of the danger. For students with mild conditions, for example where peanuts upset their stomach or other more mild reaction, CIEE still UCEAP 2012 Annual Health Update 15 of 19 SENEGAL - continued explains to them how completely unavoidable peanuts are and will require students to complete the supplemental medical release form. Required by Government: Immunization for yellow fever is required upon arrival from all countries, to be noted on the International Certificate of Vaccination (ICV). The certificate should be affixed to the visa inside of the student’s passport and presented at the port of entry. Required by CIEE: 1. Malaria prophylactic pills—all students sign a Malaria Prophylaxis Participation Agreement 2. Supplemental Medical Release for students with peanut allergy (see Appendix). Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) SINGAPORE Required by Government: International Certificate of Vaccination for yellow fever if traveling from endemic zones. The Medical Examination Report is required for students studying in Singapore for more than six months (academic year participants only). A sample form is included for reference purposes only (see Appendix). Students must use the form included with their NUS admission packet. The Medical Examination Report is required by the Singapore Immigration & Security Checkpoints Authority to issue certain immigration documents. An HIV and TB chest X-ray test are compulsory components of the medical examination. The original copy of the laboratory reports for HIV and the X-ray report must be attached to the Medical Examination Report (see Appendix). The reports will be submitted to the Singapore Immigration & Checkpoints Authority. The Medical Examination Report should be completed in the U.S. no more than three months before the student’s NUS registration date in Singapore; otherwise, it will be considered invalid. Waiting to complete the Medical Examination Report in Singapore could result in a delay with receiving the Student Pass. Required by Host University: -0SOUTH AFRICA Required by Government for visa (do not submit to UCEAP): Medical Certificate (form B1-811), one page (see Appendix). Radiological Report (form B1-806), one page. Skin TB test is acceptable to attach in lieu of Radiological Report (chest X-ray). Either the results of a TB test or an X-ray report are required to submit to the consulate in order to obtain a student visa (see Appendix). Yellow fever vaccine required if traveling from infected areas. Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course UCEAP 2012 Annual Health Update 16 of 19 SOUTH AFRICA - continued 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: • HIV is prevalent. Caution students about unsafe sex, unsterile medical or dental injections, shared needles, and unnecessary blood transfusions. Antiretroviral medications to prevent transmission of AIDS are readily available in South Africa if exposed to HIV-infected sources. • The sun intensity is strong in South Africa; sun block is recommended throughout the year, even if traveling during their winter months. In summer, a hat and sunglasses are strongly recommended. SPAIN Required by Government: • For stays over 180 days only: A medical certificate (See required text in Appendix) o The certificate must be issued in the place of residence. o The original must be translated into Spanish plus one (1) copy. o The certification on letterhead must be signed by a physician (MD or DO). Stamped signatures are not acceptable. o The certificate is valid for three months counting from the date it has been issued. o The doctor must certify that the student does not suffer from any illness that would pose a threat to public health according to WHO IHR 2005. o The certificate must bear the official stamp of the administering center; however, a stamp will not be a substitute for the doctor’s signature. o Any amendment to the certificate or erasure may render it invalid. • Visit the World Health Organization website to find the exact information regarding the control and containment of known risks to public health. • A medical evaluation may be required after arrival in Spain for visa renewal. Required by Host University: -0SWEDEN Required by Government: -0Required by Host University: -0TAIWAN Required by Government: • Yellow fever vaccine if traveling from infected areas Required by Host Universities: National Taiwan Normal University –nothing-. National Taiwan University: Medical Examination and chest X-ray results • See Appendix for a sample of the student health check list and medical exam form. • The student needs to complete the student health checklist before their exam. • The medication examination form must be completed by a healthcare professional. UCEAP 2012 Annual Health Update 17 of 19 TAIWAN - continued Chest X-ray films do not need to be submitted to UCEAP or host university. TANZANIA Required by Government: Immunization for yellow fever is required upon arrival from all countries, to be noted on the International Certificate of Vaccination (ICV). The certificate should be affixed to the visa inside of the student’s passport and presented at the port of entry. Required by CIEE: Malaria prophylactic pills—all students sign a Malaria Prophylaxis Participation Agreement Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) THAILAND Important Information about the Program: Poor air quality along with the hot and humid climate of Bangkok may affect students with asthma or other respiratory ailments. Students should consult their physician for recommendations. Medications: Adderall is illegal in Thailand, even with a prescription. Ritalin and Concerta may be possible substitutes. Wellbutrin is unavailable in Thailand. Bupropion is available under the name Quomen. Required by Government: Yellow fever vaccine if arriving from infected areas Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: There is a high incidence of dog rabies in Thailand. Advise students to avoid contact with any stray animals. Warn students to avoid places such as poultry farms and bird markets where live poultry is raised or kept, and avoid contact with sick or dead poultry. Thailand now has the highest number of officially reported AIDS cases in Southeast Asia. All travelers are cautioned against unsafe sex, unsterile medical or dental injections, shared needles, and unnecessary blood transfusions. Strongly urge students to take precautions against mosquito bites to avoid dengue fever. UCEAP 2012 Annual Health Update 18 of 19 TURKEY Required by Government: International Certificate of Vaccination for yellow fever if arriving from infected areas. Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) UNITED KINGDOM Required by Government: -0Required by Host University: -0Group C meningococcal vaccination may be required after arrival by some host universities. VIETNAM IMPORTANT INFORMATION ABOUT THE PROGRAM: This program includes study trips: a nine-day trip to central Vietnam, a nine-day trip to southern Vietnam, a four-day trip in northern Vietnam, and day trips within the Hanoi area. Students must be prepared mentally and physically for these study trips, which often include outdoor activities. Housing arrangements may be crowded, with little privacy. Limited psychological services available in English. Required by Government: Yellow fever vaccine if traveling from infected areas. Required by Host University: -0Required by UCEAP and the UCEAP Physician Consultant: 1. The successful completion of the online Travel Health Education Certification Course 2. The certification form mailed to UCEAP (see Appendix) IMPORTANT HEALTH ADVICE: Advise students to avoid places such as poultry farms and bird markets, where live poultry are raised or kept, and avoid contact with sick or dead poultry. Cholera is present and active. Observe water/food precautions. Cholera vaccine may be required if arriving from infected area or for travel to other countries. Strongly urge students to take precautions against mosquito bites. Updated: 1/27/2012 UCEAP 2012 Annual Health Update 19 of 19 2012 ― 2013 Annual UCEAP Health Update Country-Specific Health Requirements APPENDIX SAMPLE FORMS University of California Education Abroad Program Confidential Health History Form Instructions for Students (Please read carefully.) DO NOT SEND A COPY TO YOUR CAMPUS EAP OFFICE OR THE UCEAP SYSTEMWIDE OFFICE • THE UCEAP HEALTH CLEARANCE IS A NON-WAIVABLE REQUIREMENT TO PARTICIPATE IN EAP. IF YOU ARE NOT IN COMPLIANCE WITH ALL ASPECTS OF THE HEALTH CLEARANCE, YOU MAY NOT BE APPROVED TO PARTICIPATE IN, OR MAY BE DISMISSED FROM EAP. • Use this confidential form with the “UCEAP Health Clearance” form. • You must complete the attached form accurately and truthfully BEFORE the health clearance consultation. • Failure to provide complete and accurate information may be grounds for non-participation in EAP. • The UCEAP Systemwide Office (UCEAP) must be informed of any recent medical or special needs or changes in health that occur after the health clearance. Students will be required to get a second clearance should their health status change since the date of the first clearance. • It is vital to disclose all medical history to the health provider performing your clearance; even if you do not believe that a condition might create a problem for you while abroad. Full disclosure will allow medical professionals to help you make necessary arrangements or plans to ensure you have a successful experience. Identifying medical or mental health problems allows everyone involved the opportunity to work with you to make your program a success. Students with known and chronic medical conditions, such as allergies or diabetes, must take special precautions in preparing for, and managing their condition abroad. You need to anticipate how the new environment and the stresses of study abroad will affect your health. Preexisting psychological conditions are often intensified by living in a different culture. There may be even fewer local resources to help a student manage potential triggers. Students Using Medication 1. If you use medication -- including asthma inhalers and oral contraceptives -- on a regular basis, you should take a supply to last throughout your stay and carry a letter from your physician on letterhead explaining the medical necessity and treatment. 2. When going through Customs abroad, officials may scrutinize prescription medication. Carry your prescription in original containers, and have a letter from your physician. Medications that are legal and readily available in the U,S, may be considered illegal, require a prescription, or a host country authorization to be allowed in the country. You must find out whether your prescription medication is available and legal at your destination. Refer to #5 below. 3. If you are taking a psychotropic, you must be stable on your medication before starting your UCEAP experience. Medically stable means that you must be in a state where any changes in symptoms are not foreseen or expected. Discuss proper medication management with your doctor. 4. If you are being treated for a psychological health condition, work closely with the physician to understand possible triggers, what medications you are taking and if they are available overseas, and how to reach out for help while abroad, if needed. You are expected to have a treatment plan identifying a therapist and frequency of appointments. 5. Mailing medication abroad: Most countries have very strict regulations on having medications shipped abroad. Students find that refills of regularly taken medications in the U.S. get stopped by the host country's Customs. Decisions on what medications may be mailed legally into some foreign countries are made by the Host Country Government; not the U.S. Post Office. Students should call the host country government office in the U.S. or Europ Assistance (EAP emergency travel insurance) at 1+(866) 451-7606 (inside the U.S.) or call collect 1+(202) 828-5896 (from outside the U.S.) or E-mail [email protected], to get information about the legality of certain medicines. Please contact them with the name of the medicine and the country. Instructions FILL OUT this form completely and honestly before your health clearance appointment. TAKE the completed form with you and discuss your health history during your health clearance. GIVE a copy of this form to the health care professional who performed your clearance. KEEP original with your passport, in case of emergency. TAKE a copy abroad in case of a medical emergency. Do not mail a copy to the UCEAP Systemwide Office. MAKE ADDITIONAL COPIES of this form. You can give a copy to a health care provider abroad and to the Study Center Office abroad in case of a medical emergency. UCEAP Confidential Health History Form A health clearance must be completed 60 days before departure (except for Chile). The UCEAP health clearance is a non-waivable requirement. IF YOU ARE NOT IN COMPLIANCE, YOU MAY NOT BE APPROVED TO PARTICIPATE IN, OR MAY BE DISMISSED FROM EAP. This form and a review of your medical record on file will be used during the health clearance process. UCEAP must be informed of any recent medical or special needs or changes in health that occur before the start of the program. Failure to provide complete and accurate information may be grounds for non-participation in UCEAP. Complete the following information BEFORE your medical appointment. Failure to provide complete and accurate information may be grounds for non-participation in EAP. Failure to disclose health care problems may also lead to serious medical consequences, including death while studying abroad. PRINT: Last name First Sex: M Middle F Student I.D. Program/Country Person to notify in case of emergency: NAME ADDRESS: STREET CITY STATE, ZIP CODE PHONE, INCLUDE AREA CODE GENERAL HEALTH: List any recent or continuing health problems: List any physical or learning disabilities: ________________________________________________________________________________________ Are you currently under the care of a doctor or other health care professional, including mental health treatment? Doctor’s Name: Yes No Phone/Fax: Address: For what condition(s): SURGERIES: List type and year DRUG/FOOD ALLERGIES: List any drug or food allergies and briefly describe reaction: MEDICAL HISTORY: Students with known and ongoing medical conditions must prepare for and manage their condition overseas. Complete below: Y N Date Y Headaches N Date Y Ulcer/colitis Back/joint problems Epilepsy/seizures Hepatitis/gallbladder High blood pressure Asthma/lung disease Bladder/kidney problems Thyroid problems Heart disease Diabetes Recurrent or chronic infectious diseases Anemia or bleeding disorder Cancer/tumors N Date Other (List) MENTAL HEALTH HISTORY: Have you ever suffered from, been treated for, or hospitalized for the following? Y N Please provide an explanation below for any box you have checked Any mental health condition, such as depression/anxiety Substance abuse (alcohol or drugs) Eating disorder (anorexia/bulimia) Are you taking/have ever taken medication for above problems? IMMUNIZATION RECORD: Indicate most recent date. Date Date Date Polio immunization Measles Mumps Tetanus booster or Tetanus/diphtheria booster Rubella MMR MEDICATIONS: Student is responsible for ensuring that all medications are legally permissible abroad. Are you currently taking any medications? Y N Please specify below; include any medication you carry for use, e.g., inhaler, bee sting kit. SERVICES YOU WILL NEED TO FACILITATE YOUR EDUCATION (e.g., note takers) I certify that all responses made on this form are complete, true and accurate. I understand that if there are any changes in my health status, I will contact UCEAP immediately. I understand that if I withhold information on this form I may be withdrawn from the program. Student’s Signature: Date: Student copy to keep with passport in case of a medical emergency. Student may make additional copies for health care provider and Study Center Office abroad. One copy: Health care professional who performed EAP clearance. DO NOT SEND A COPY TO UCEAP. 1/11 UCEAP Health Clearance Form STUDENT INSTRUCTIONS Refer to your UC Campus EAP Office health instructions too. The UCEAP health clearance is a mandatory requirement for participation. All information is confidential and only shared to facilitate assistance, particularly during an emergency. 1. Do not delay in making your health clearance appointment. The health clearance deadline is no later than 60 days before departure (except for Chile). Students who are not in compliance may not be approved to participate in, or may be dismissed from UCEAP. 2. Complete the Confidential Health History form (if your campus has online clearance procedures, follow them). 3. Write your name, UC campus, and UCEAP program name, host institution, and term, on the attached form before your appointment. 4. Inform the UCEAP Systemwide Office (UCEAP) of medical needs, accommodations, and/or changes in health that occur after the health clearance process. Failure to provide complete and accurate information may be grounds for non-participation in, or dismissal from, UCEAP. 5. Return the original and a copy by the stipulated deadline to: UCEAP Systemwide Office University of California 6950 Hollister Avenue, Suite 200 Goleta, CA 93117-5823 HEALTH CARE PROVIDER INSTRUCTIONS—R E A D c ar efu l ly b e fo r e s ign in g th e fo r m Health provider must be licensed to practice and cannot be an immediate family member (AMA Code of Ethics E-8.19) • The student’s name and program information must appear on the form. Blank forms are not acceptable. • University of California will not approve a student’s participation in EAP unless you certify that the student is medically stable. FOLLOW THESE STEPS: 1. The student must present to you a completed UCEAP Confidential Health History form. A physical examination is not needed unless required by the program, or UC Student Health Center. 2. Discuss/review the student’s health history referring to the Confidential Health History form completed by the student and the student’s medical records on file. 3. Pay special attention to any physical, emotional or psychological conditions that may require medication and/or continued therapy while abroad. a. Students may be cleared for participation if i. in the opinion of the examining practitioner and/or specialist, if being treated by one, any medical condition is under control, ii. they have a contracted treatment plan in place (if there is any evidence of recent physical/mental health treatment), for required and recommended care while abroad, and iii. they have been stable on their medication for a reasonable period. 4. Student is advised to find out if the medication is locally available or if there is an appropriate substitute. If not locally available, student is advised to carry a sufficient supply to last through UCEAP, but only if the medication can legally be brought into the country. 5. List any disabilities the student may have so UCEAP can help the student to determine the availability of adequate local services. The student must be assessed to participate in UCEAP by a physician/health practitioner and a specialist if a student is currently being treated for a chronic condition. Health practitioners must complete and sign this clearance form, and provide legible contact information. University of California UCEAP Health Clearance Form STUDENT: Print clearly with a ball point pen before appointment First and Last Name of Student UC Campus UCEAP Program Name (Country Host University Term) HEALTH PROVIDER: Health provider must be licensed to practice and cannot be an immediate family member (AMA Code of Ethics E-8.19). Only disclose information that is necessary and relevant to UCEAP’s duties. I have reviewed the student’s Confidential Health History form, and medical records on file, with the student. Based on the information provided to me by the student on the Confidential Health History form, and following a review of the student’s personal health history, to the best of my knowledge, the student is: Licensed Psychotherapist or Licensed Specialist (Section & signature required if student is being treated for chronic health conditions.) 1. CLEARED (Check all that apply below) 1.a No medical or psychiatric contraindications to UCEAP participation. 1.b Student advised to arrange services to facilitate education (e.g., note-taking, wheelchair access). A letter from the UC Disability Services Office documenting disability and indicating who will pay for services is required. 1.c. Student advised to arrange services to facilitate a healthy and safe stay abroad (e.g., regularly available psychiatric therapy, etc.). Indicate that student has treatment plan in place and is stable. 1.d Student advised to find out if medication (or appropriate substitute) is locally available. If not locally available, student advised to carry a sufficient supply to last through the end of the program. If on medication, please list. Indicate if significant allergy to any medication. 2. Student is NOT CLEARED: There are medical or psychiatric contraindications to UCEAP participation. Licensed Specialist –OR– Psychotherapist (PRINT LEGIBLY name and title): __________________________________________________________________________________ Phone number (include area code): Signature:__________________________________________________________________________ Date: Licensed Physician/Health Practitioner 1. CLEARED (Check all that apply below) 1.a No medical or psychiatric contraindications to UCEAP participation. 1.b Student advised to arrange services to facilitate education (e.g., note-taking, wheelchair access). A letter from the UC Disability Services Office documenting disability and indicating who will pay for services is required. 1.c. Student advised to arrange services to facilitate a healthy and safe stay abroad (e.g., regularly available psychiatric therapy, etc.). Indicate that student has treatment plan in place and is stable. 1.d Student advised to find out if medication (or appropriate substitute) is locally available. If not locally available, student advised to carry a sufficient supply to last through EAP. If on medication, please list. Indicate if significant allergy to any medication. 2. Student is NOT CLEARED: There are medical or psychiatric contraindications to UCEAP participation. Licensed Physician/Health Practitioner, MD, NP, DO, PA, or RN, (PRINT LEGIBLY name and title): __________________________________________________________________________________ Phone number (include area code): ________________________________ Signature: __________________________________________________________________________ Date: ____________________________ Upon completion, the student must send copies of this form to UCEAP by the deadline. UCEAP will mail one copy to the UCEAP Study Center. PHYSICIAN RUBBER STAMP OR BUSINESS CARD HERE One copy: Health care provider – Original & 1 copy: UCEAP Systemwide Office, 6950 Hollister Avenue, Suite 200, Goleta, CA 93117-5823 THE UNIVERSITY OF THE WEST INDIES CAVE HILL CAMPUS CONFIDENTIAL MEDICAL QUESTIONNAIRE TO BE COMPLETED PRIOR TO ACCEPTANCE FOR ADMISSION TO THE UNIVERSITY OF THE WEST INDIES (CAVE HILL CAMPUS) Part A is to be completed and signed by the applicant Part B is to be completed by a Registered Medical Practitioner who has examined the applicant. Both parts must be completed by writing “Yes” or “No” in the proper space. If “Yes” is answered, the details relevant to the question must be inserted. Positive answers do not necessarily imply the refusal of the applicant. Answers given to the questions will be of assistance to the student in his/her University career. PART A Applicant’s Last Name: First Name(s): Address: Age: Name of Parent/Guardian/Next of Kin: No 1. Have you ever had: Hypertension Asthma Diabetes Epilepsy 2. Is there any physical or mental disorder for which you may need special attention or supervision during your studies? SIGNED: _________________________ DATE: _________________________ Yes Details PART B TO BE COMPLETED BY THE PHYSICIAN AFTER PART A HAS BEEN COMPLETED BY APPLICANT ✍ Please note below any conditions you consider significant. If there is any other information of which we should be aware please submit separately under confidential cover. No 1. Is there any abnormality on general physical examination including urine test? 2. *Is there any physical or mental disability which might handicap the candidate in his/her studies? 3. Is there any evidence of recent infectious disease? 4. Is there any history of allergies or adverse drug reactions? 5. Has the candidate been treated for any of the following: Asthma Epilepsy Hypertension Diabetes 6. **Is the candidate immunized against: Tetanus Diphtheria Anterior Poliomyelitis B.C.G. Rubella Hepatitis B Yes Details *If YES, please forward, thorough patient medical details under confidential cover, to Doctor, Student Health Service, The University of the West Indies, Cave Hill Campus **Patient is required to submit documented details SIGNED: _____________________________________ FULL NAME: _____________________________________ ADDRESS: _____________________________________ _____________________________________ _____________________________________ DATE: _____________________________________ Sample Chinese health form for BNU FALL and PKU YEAR students only (X Visas). Physician must fill out each box. Last, first (must match passport) Nationality must match your passport This entire section must be completed in full by the physician. Please note metric sizes and weights (cm, kg) DD-MM-YYYY State and country Photo officially stamped by clinic, hospital, or physician. Physician must indicate something in each box, even if it is "none found." Attach original X-ray report, not films. Photocopies are not accepted. Attach original printout. Must state clearly: AIDS-negative or positive Syphillis-negative or positive The original HIV test must be attached, photocopies are not accepted. If none found, physician should write "none found" Official stamp of clinic, hospital, or physician. An address stamp is ok. if any or whoever did the exam DD-MM-YYYY Egypt Egypt SAMPLE: Ghana MALARIA PROPHYLAXIS PARTICIPATION AGREEMENT I (Print Student Name)________________________________________________________ understand that malaria is present throughout Ghana year-round, including in urban areas. I understand that travelers to sub-Saharan Africa have the greatest risk of both getting malaria and dying from their infection. I understand that transmission is generally higher in Africa south of the Sahara than in most other areas of the world. I understand that most residents of the United States have never developed resistance (immunity) to the disease and that malaria infection in a non-immune person can quickly result in a severe and life-threatening illness. I agree to consult with my UC campus Student Health Services physician before my participation in the Education Abroad Program in Ghana regarding the anti-malaria prophylaxis treatment most appropriate and learn about personal protective measures. I agree to continue the prescribed malaria prophylaxis regime through my stay in Ghana and that missed or delayed doses may increase the risk of getting malaria. I understand that such malaria prophylaxis is required by the regulations of the University of Ghana. I understand that anti-malarials are not 100% effective so insect protection measures are essential in addition to any prophylactic regimen. I agree that I will follow personal protection measures (i.e. wear appropriate clothing, use permethrin-treated bed nets, use of aerosol insecticides, vaporizing mats and mosquito coils, etc.) As a voluntary participant in the Education Abroad Program at the University of Ghana, I will follow the doctor’s recommended malaria prophylaxis as prescribed and I certify that I have read and understood the above. I understand that failure to comply with these requirements could result in my dismissal from the program. Signature of Student _______________________________________________ _______________ UC Campus Updated January 2012 ______________________ Date Student I.D. No: STRICTLY CONFIDENTIAL College: 香 港 中 文 大 學 保 健 處 Faculty: THE CHINESE UNIVERSITY OF HONG KONG UNIVERSITY HEALTH SERVICE Photo 健康記錄表 Department: HEALTH HISTORY FORM Name: (Surname, Other names) Sex: M/ F (Chinese) Date of Birth: Place of Birth: Marital Status: Single/ Married Home Address: Phone: Home: Correspondence Address (if different): Nationality: PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: Relationship: Name: Phone: Mobile: Address: FAMILY HISTORY: Relation Sex/Age State of Cancer Health 癌症 健康狀況 Occupation Do your family member ever had the followings: (please √) Heart Hypertension Diabetes HyperMental Disease 高血壓 糖尿病 cholesterolemia Illness 心臟病 高膽固醇 精神病 If Deceased Cause & Age of Death Father Mother Brothers & Sisters HEALTH PROBLEMS: Have you ever had the followings? Allergic Rhinitis 鼻 敏 感 Yes □ 心 臟 病 Yes □ Asthma 哮 □ □ Hypertension 高 血 壓 □ □ Hepatitis B Carrier 乙肝帶菌者 □ □ Eczema/Dermatitis 濕疹/皮膚炎 □ □ Diabetes Mellitus 糖 尿 病 □ □ Tuberculosis 肺結核病 □ □ Thyroid Disease □ □ Hypercholesterolemia 高膽固醇 □ □ Venereal Disease 性 病 □ □ 腎 精 神 病 □ □ 其他病症 □ □ 喘 甲狀腺病 No □ Heart Disease No □ Acute Hepatitis Ulcer Pain 胃 痛 □ □ Kidney Disease 病 □ □ Mental Illness Anaemia 貧 血 □ □ Epilepsy 羊 癇 症 □ □ Other Diseases Operation 手 術 □ □ Hospitalization 住 □ □ 院 急性肝炎 Yes □ No □ If yes, please specify (Date; Duration; Treatment & Follow-up): LONG TERM MEDICATIONS 長期服用藥物 Name Dosage & Frequency 1. 2. Are you ALLERGIC to any food/ medications? 你是否對某種藥物/食物敏感？ Yes □ No □ Date started (if known) If Yes, please specify? 如有，請列明。 _____________________________ MENSTRUAL HISTORY (For female students only) 月經週期 (只適用於女生) Age of first menstruation 首次月經年齡: Duration between periods _______ ______ Days 月經週期: Quantity of menses 月經流量: □ Menstrual Pain 經痛: □ nil 沒有 Number of days of menses scanty 微量 □ □ □ excessive 很多 mild 輕微 moderate 中等 □ ______ Days 月經日數: moderate 適中 □ severe 嚴重 Do you smoke? Yes □ No □ If yes, please specify how many? __________ pack /day __________years Do you drink alcohol? Yes □ No □ If yes, please specify how much? __________ drinks /week In the past 3 months, did you have: 最近三個月內，你曾否有： (i) Cough for more than 4 weeks? 咳逾四星期？ (ii) Cough with blood stained sputum? 咳血現象？ (iii) Unexplained low grade fever? 不明原因的持續發燒？ (iv) History of contact with T.B. patients? 曾與肺結核病人接觸？ Do you frequently have insomnia, feel anxious or emotional upset? 你是否經常失眠、焦躁不安或情緒不穩定？ Do you need counseling or like to discuss confidentially with the health staff for your personal, health, social or emotional problem? 你是否想與醫護人員單獨商討你個人健康、心理輔導或其他指導？ Do you have any physical handicap which may require special provisions to adjust to university life? 你傷殘與否？是否需要援助？ Do you have amblyopia? 你是否弱視(視力模糊，不能用鏡片矯正)？ Are you troubled by any defect in speech? 你是否有言語障礙？ Do you have any impairment of hearing? 你是否弱聽？ IMMUNIZATION 防疫注射 (Please √ and including dates if possible) First Dose Second Dose Third dose Hepatitis A 甲型肝炎 Hepatitis B 乙型肝炎 Twinrix 甲乙型肝炎 Poliomyelitis 小兒麻痺 DPT (Triple Vaccine) 白喉,破傷風,百日咳 Diaphtheria-Tetanus 白喉,破傷風 Tetanus Toxoid 破傷風類毒素 Date:_____________________ First Dose Height (m) University Health Service BMI The Chinese University of Hong Kong Remarks August 2008 □ □ □ □ □ □ □ Yes □ No □ □ □ Yes □ No □ □ □ □ □ □ □ Student Signature:________________________ The Director / □ Second Dose Body Weight (kg) Blood Pressure No Measles, Mumps, Rubella 麻疹,腮腺炎,德國麻疹 BCG 卡介苗 Chickenpox 水痘 Influenza 流感 HPV Vaccine 預防子宮頸癌疫苗 Other Vaccines 其他疫苗 RETURN COMPLETED FORM TO: For Official Use Yes Shatin, N.T. IES in India - 2012-2013 SAMPLE FORM Thursday, January 05, 2012 9:16 AM Unfiled Notes Page 10 Unfiled Notes Page 11 SAMPLE: Pune, India Contemporary India: Development, Environment, Public Health Medical Form INSTRUCTIONS The medical form must be completed by all students as a condition of their participation in the Alliance for Global Education’s Program in Pune, India. Failure to submit the medical form on time or to answer all questions will jeopardize your participation in the program. Your participation is contingent upon our evaluation of your medical history and any limitations that could affect your experience abroad. By submitting this form you are agreeing to the program’s right to review and determine your fitness to participate in the Program; if for any reason the Program deems you unfit to participate, your deposit will be refunded in full. The guidelines below will assist you in completing your medical form. Please be advised that leaving anything blank on your medical form may compromise your approval process. Your medical form will not be reviewed until all completed parts are received. PART I This is the portion that you fill out. Please complete all questions in “Part I: Medical History” and provide it to your medical practitioner to review before he or she completes Part II. Childhood Immunizations: Information needed to complete this section can be obtained from your high school or university health center, your physician's office, or your parents. India-Specific Immunizations and Malaria Prophylaxis: Discuss India-specific immunizations and malaria prophylaxis with your medical practitioner after first consulting the CDC website to learn what is recommended (http://wwwn.cdc.gov/travel/destinationIndia.aspx). Be sure to ask your medical practitioner about drug interactions between certain malaria prophylaxes and other prescription medications, especially those used for depression or anxiety. Authorization to Release Medical Records and Permission for Emergency Medical Treatment: Please be sure to write in the name of your physician or health care provider immediately after your name, and complete the rest of the page. PART II Your physician (MD), Physician’s Assistant (PA), or Nurse Practitioner (NP) completes “Part II: Physician’s Report and Examination.” The completion of Part II must be based upon a physical examination conducted within twelve months of the program start date. The medical practitioner must complete and sign the “Physician’s Authorization.” Please note: we do not accept reports completed by a relative. PART III Students who answered in the affirmative to specific questions under Part I (Past and Current Conditions) must have Part III filled out completely by the person who treated or is treating you. In the case of multiple affirmatives, a separate Part III must be completed for each condition. P 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. PART I: Personal Medical History Name (family, first, middle) _________________________________________________ Birth date (month/day/year) __________________ Male ____ Female ____ Mailing address __________________________________________________________ __________________________________________________________ Telephone (campus) ________________________ (home) __________________________ (cell) _________________________ Home School ____________________________________________________________ CHILDHOOD IMMUNIZATIONS: These shots are the minimum required. Consult the CDC and your personal physician for other recommended immunizations. Measles (first date) __________________________ (second date) ______________________________ Diphtheria/Tetanus (required within ten years) ____________________________ Mumps ____________________________________ Rubella (German measles) ___________________ Polio ______________________________________ Other ____________________________________ PERSONAL HISTORY Please check if you have or have had: Tuberculosis Scarlet fever Measles Rubella (German measles) Chicken pox Rheumatic fever Hepatitis Malaria Polio Food allergies (please specify) Depression Chronic cough Heart palpitations Chronic indigestion Bleeding/clotting problems Cancer or leukemia Irregular periods Appendectomy Tonsillectomy Hernia repair Immune system problems Shortness of breath, wheezing Recent weight gain or loss Recurrent dizziness/faintness Gall bladder trouble Hernia (rupture) Sinus problems Kidney Stone Albumin or blood in urine Abdominal pain Painful/swollen joints Back problems Severe menstrual cramps Asthma Eczema Hay fever Heart murmur Unexplained fever Epilepsy Hearing loss Eye trouble Chest pain, pressure Severe headaches Chronic rash Stomach Ulcer Chronic diarrhea Anemia Impaired use of any limbs Joint problems Tobacco ____/____ Other (please specify) _______________________ Habits (how much/often) Alcohol ____/____ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. Comment below on any condition(s) above that you have checked. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ FAMILY HISTORY Have any immediate family members had: Tuberculosis Epilepsy/convulsions Asthma Heart disease Diabetes Other PAST AND CURRENT CONDITIONS Please complete the following, adding additional paper if necessary. DO NOT LEAVE ANY QUESTION BLANK. A. Has your physical activity been restricted during the past three years? (If so, give reasons and duration.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ B. Have you consulted or been treated by clinics, physicians, or other practitioners within the past three years, other than routine check-ups? (If yes, give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ C. In the last five years, have you consulted or been treated by a psychiatrist, clinical psychologist, drug/alcohol counselor, or other mental health professional? (If yes, explain here, and have your counselor or physician complete Part III.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ D. Have you been hospitalized in the last five years? (If yes, give diagnosis and date.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. E. Have you ever had a serious acute illness? (If yes, give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ F. Do you have any chronic/recurrent illness or injury? (If yes, explain here, and have your counselor or physician complete Part III.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ G. Have you had any allergic reaction to prescription or over-the-counter medicines? (If yes, give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ H. Have you had any allergic reaction to past immunizations? (If yes, give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ I. Are you currently taking any medications, including oral contraceptives? (If yes, list and give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. J. Are you currently receiving antigen/immunotherapy injections or prescription medication for an allergy? (If yes, explain here, and have your counselor or physician complete Part III.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ K. Do you have any health requirements or dietary restrictions based upon religion? (If yes, give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ L. Do you have any history of eating disorders? (If yes, explain here, and have your counselor or physician complete Part III.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ M. Do you have any habits that might adversely affect your health? (If yes, list and give details.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ N. Do you have a learning disability, or any hearing, visual, or physical impairment that might require accommodation? (If yes, please provide any supporting documentation and have the appropriate medical professional or specialist complete Part III.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ If applicable: ____Documentation is attached ____I plan to submit documentation at a later date ____I do not plan to submit documentation at this time 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. The Alliance for Global Education will work to assure reasonable arrangements for students with documented disability conditions (e.g. physical, learning, psychiatric, visual or hearing impairments). If you presently require such arrangements at your home school or anticipate needing them while in India, please let us know so that we can work with our resident staff to make suitable arrangements while you are abroad. The information you provide on this form is considered confidential. Only those individuals who need to know will have access to this information. Because we want you to enjoy a successful and rewarding study abroad experience, we encourage you to disclose all of your disability-related needs on this form, immediately following your acceptance to the program. If you choose not to disclose your need for special arrangements, The Alliance will not be able to help provide them for you. Supplying us with this information does not commit you to partaking in services, nor does it confirm that services will be available. The Alliance for Global Education cannot guarantee that all types of disability conditions can be accommodated in all locations. AUTHORIZATION TO RELEASE MEDICAL RECORDS AND PERMISSION FOR EMERGENCY MEDICAL TREATMENT Please complete and sign the following: I, _______________________________________ (full name of student), hereby authorize ______________________________________ (name of physician or other medical practitioner) to release any or all medical records or information pertaining to me attending the Alliance for Global Education Program. I also authorize the release by the Alliance for Global Education of my medical records or other medical information pertaining to me to my parent or other designated contact person in the event of an emergency during the Alliance for Global Education Program. On rare occasions, an emergency requiring treatment in a hospital and/or surgery may develop. In most cases, administration of an anesthetic, treatment of an injury, or operation upon an individual cannot be done without consent of the patient. In order to prevent a dangerous delay in an emergency situation where the Alliance for Global Education is either unable to contact my parent or guardian, or if I am unconscious or otherwise unable to give you my consent, I hereby authorize the Alliance for Global Education’s representative to secure whatever medical treatment is deemed necessary, including administration of an anesthetic and surgery. I hereby verify that all of the information contained in this form is accurate and acknowledge that any failure to provide accurate information may result in my dismissal from the program. I agree to notify the Alliance for Global Education of any material changes in my health that occur prior to the start of the program. Signature of student ________________________________________________ Date (month/day/year) _________________________________ Person to contact in an emergency ________________________________________________________ Telephone (home) ________________________ (work) _______________________ (cell)________________________ Relationship to student _______________________________________________ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. PART II: Physician’s Report and Examination TO THE EXAMINING PHYSICIAN: All participants in the Alliance for Global Education Program will be fully active in the Indian culture. They will be in varying conditions of sanitation and will have uncertain access to Western-style health facilities and psychological services. For these reasons you are asked to carefully consider the student’s general fitness and physical and mental health in relation to the country, the type of program, and the conditions in which the student will be living. Please note: we do not accept medical evaluations completed by a relative. Please review the student’s history and complete this form. Also, please comment on any positive answers given by the student in Part I and provide any additional information that could be useful in the event of treatment by a doctor or other medical facility abroad. This information is strictly for the use of the Alliance for Global Education Program and will not be released without the student’s consent. Please mail or fax immediately to: The Alliance for Global Education ATTN: Amanda Zimmerman 450 S. Easton Road Glenside, PA 19038 (Tel.) 888.232.8379 • (Fax) 215.572.2174 PLEASE DO NOT LEAVE ANY QUESTIONS BLANK. Are there any abnormalities of the following systems? If yes, give details on the next page. Yes No Head, eyes, ears, nose, or throat Teeth, gums Skin Immune system, including lymph nodes Cardiovascular Respiratory Breasts Gastrointestinal Is this student seriously underweight or overweight? Yes No Hernia Metabolic/Endocrine Genitourinary Pelvic Musculoskeletal Neurologic Mental status Yes No Does this student have any eating disorders, such as bulimia or anorexia? Yes No Does this student have any allergies (including allergies to medication and/or food)? Yes No If student has allergies, is there history of asthma, anaphylaxis, or other dangerous allergic conditions? Yes No Is this student currently under medical treatment or taking medication? Yes No Does this student have any speech, hearing, eyesight, or physical impairment that might affect his or her participation in this program? Yes No Is there any history of behavioral disorders or emotional disturbances, such as abnormally severe mood swings? Yes No 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. Has this student been under psychiatric treatment? (If “yes,” permission will be asked of the student for a confidential report from the psychiatrist.) Yes No Is there any congenital malformation, chronic condition, physical impairment, or learning disability that may require additional treatment or accommodation over the next year? Yes No Would carrying luggage or conducting strenuous travel cause the student hardship? Yes No Does this student have any menstrual difficulties that might limit participation in active programs? Yes No Please give details on any questions to which you have answered yes or on any points of concern in your examination or in this student’s personal medical history in Part I. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Do you have any recommendations regarding the care of this student? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Recommendation for physical activity: Unlimited Limited (If limited, please explain.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ PHYSICIAN’S AUTHORIZATION Having examined this student and reviewed his or her past medical history, I, _______________________________________________________________ (name of medical practitioner), consider that ______________________________(name of student) is fit to participate in a program in India. Having received permission from said student, I would be willing, if indicated, to discuss issues pertaining to this student’s health status with the professional staff of the Alliance for Global Education and will furnish pertinent medical records upon request. Signature of physician _____________________________________________________ Date (month/day/year) ________________________________ Mailing address __________________________________________________________ Telephone _________________________________________ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. PART III: FURTHER MEDICAL INFORMATION FOR OVERSEAS TRAVEL The following release is only to be signed by the student if the medical professional completing Part III is different from the person completing Part II. AUTHORIZATION TO RELEASE MEDICAL RECORDS Please complete and sign the following: I, ___________________________ (full name of student), hereby authorize _________________________________________ (name of physician or other medical practitioner) to release any or all medical records or information pertaining to me to the Alliance for Global Education Program. I also authorize the release by the Alliance for Global Education of my medical records or other medical information pertaining to me to my parent or other designated contact person in the event of an emergency during the Alliance for Global Education Program. Signature of Student _______________________________________________ Date (month/day/year) ________________________________ _____________________________________________________________________________________________ TO THE APPROPRIATE MEDICAL PROFESSIONAL: In order to ensure the student’s well-being, it is important to have complete medical information. Not all students are adapted to all programs, and this process attempts to ensure that the student has not selected a program that is too physically or emotionally challenging. In addition to taking a full academic course-load, all participants in the Alliance for Global Education Program will be fully active in the local Indian environment, which will involve varying conditions of sanitation and potentially uncertain access to Western-style health facilities and psychological services. For this reason, we require full medical disclosure of any physical or mental health condition or learning disability that could potentially be problematic for a student overseas. Please give as much detail as possible in answering the following questions. Also, feel free to call the Alliance for Global Education with any questions. Please mail or fax immediately to: The Alliance for Global Education ATTN: Amanda Zimmerman 450 S. Easton Road Glenside, PA 19038 (Tel.) 888.232.8379 • (Fax) 215.572.2174 Please include appropriate relevant medical records and any information necessary for medical personnel overseas who might be treating this student. 1) Describe, in as much detail as possible, the relevant health condition, disability, or impairment. For allergies, please indicate what this student is allergic to, how he or she reacts to it, and any medications that should or should not be used by the student overseas. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2) How long has the student suffered from this condition, and when was it diagnosed? (Give specific dates.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. 3) How was this condition treated and for how long? (Give specific dates, medications, etc.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 4) Are there currently any problems or issues of concern regarding this condition? (Describe plans for testing or treatment.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 5) What is the prescribed plan in the event that this condition becomes an acute or emergency situation overseas? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 6) What are the limitations, if any, on this student’s participation in an extremely emotionally and physically rigorous overseas program? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ MEDICAL PROFESSIONAL’S AUTHORIZATION I, ____________________________________ (name of medical professional), consider that ____________________________________ (name of student) is fit to participate in the Alliance for Global Education Program in India and will send along with said student any medical records needed for possible treatment by a physician or medical facility abroad. Having received permission from said student, I am willing to further discuss problems pertaining to this issue with the professional staff of the Alliance for Global Education. Signature medical professional ______________________________________________________ Title ______________________________________________________ Date (month/day/year) ________________________________________ _____________________________________________________________________________________________ Mailing address ______________________________________________ ______________________________________________ Telephone __________________________________________________ 450 S. Easton Road, Glenside, PA 19038 ● 1-888-232-8379 ● www.allianceglobaled.org The Alliance for Global Education, LLC is a not-for-profit partnership of the College of Global Studies at Arcadia University and the Institute for Study Abroad, Butler University. HITOTSUBASHI UNIVERSITY 健 2011 年度 診 CERTIFICATE ※ 判 康 定 断 OF HEALTH Do not fill in. 一橋大学 ※ 受験番号 検査不要・要再検・要精密 Do not fill in. Do not fill in. ※ 志望学部・研究科 Intended Course of Study 書 研究科 Research Course in 名（漢字には、ふりがなをふること） Name of Applicant 姓(Family) 生 年 月 日 Date of Birth 現 在 所 Current Address and Phone Number 年 Year 月 Month 日 Day □ 男 性別 Sex □ 女 Male Female Tel 〒 診 断 事 項 健康の状態 (Middle) 名(Given) （Examination Report） (Current State of Health) Without Glasses 視 力 Eyesight 左 右 Left (With Glasses) □有 □無 ＋ － ( ／ ) ( 治療歴 ) □有 □無 ＋ － History of Treatment 左 Left 右 Right □現在治療中 Currently Under Treatment If you marked ＋, please describe in detail. 有の場合具体的に 結 核 Tuberculosis 聴 力 Hearing Right 胸部Ｘ線撮影日 年 月 日 Date of Chest X-ray Year 学業上配慮すべき障害に関する所見 □ 有 ＋ Diseases or Disorders (Mental or Physical) □ 無 － If you marked ＋, please describe in detail. □ 有 主な既往症 Past medical history we should know 有の場合具体的に Day (Disabilities With Respect to Study) 心身の疾病又は障害に関する所見 有の場合具体的に Month □ 無 Yes No If you marked ＋, please describe in detail. 総合所見：この志願者の健康状態は、一橋大学における学業に差し支えありません。 In my opinion, the applicant is physically able to study at Hitotsubashi University. 診断日 年 Date of Examination Year 月 Month 医療機関名(Hospital/Clinic) 住所（所在地）（Address） 医師名（Name & Title of Physician） 署名／捺印 (Physician’s Signature/Seal) Yes 日 Day □はい □いいえ No Please handwrite them NEATLY and CLEARLY Keio University For exchange students 健 康 診 断 書 Certificate of Health 注意事項 IMPORTANT NOTE この健康診断書は、現在の健康状態で問題なく留学生活を送れるかどうかを把握するためのものです。 *医師に診断を受け正確に記入をしてもらってください。感染症の免疫が確認できない場合にはワクチン接種を強く推奨しています。胸部X線撮影は必ず検査を受けるよう にしてください。 The purpose of this form is to understand the student's health conditions that may affect his/ her studies before he/she comes to Japan. *This form must be completed by a medical physician. If student does not have antibodies against the infectious diseases listed below, we strongly recommend to get vaccinated. X-ray examination is mandatory for all students. 氏名 Name 姓 Family 名 Given Middle 国籍 Nationality 生年月日 Date of Birth 19 年 Year 月 性別 Sex 日 Month Day □ 男 Male □ 女 Female 診断事項・健康の状態 Examination Report・Current State of Health 視力 Eye-sight 聴力 Hearing 胸部X線検査 Chest X-ray 左 (L) 右 (R) □ 裸眼 Without glasses or contact lenses □ 矯正 With glasses or contact lenses □ 正常 Normal □ 異常 Impaired □ 正常 Normal □ 異常 Impaired 撮影日 Date 年 Year 月 日 Month Day 所見があれば記入してください。 Describe the condition in detail. 感染症などの病歴について Record of infectious diseases and immunization 以下の感染症にかかったこと、および予防接種を受けたことがありますか。 Have you ever had the following diseases and/or received vaccination? 麻疹 Measles □ Yes 流行性耳下線炎 Mumps □ Yes Vaccination Date: Vaccination Date: □ No / / □ No / / 風疹 Rubella □ Yes 水痘 Varicella □ Yes □ No Vaccination Date: / / □ No Vaccination Date: / / 学業上配慮すべき健康上の問題 Medical conditions which might affect the student's academic performance □ 有 Yes 主な既往症や持病はありますか。 Does the student have any serious past medical history or chronic illness? □ 無 No 有の場合、病名と治療完了日を記入してください。 If "Yes", please indicate the name of the disease and recovery date. 例）気管支喘息、心臓病、てんかんなど。 eg）Bronchiala asthma, Cardiac diseases, Epilepsy etc. 心身の疾病または障害に関する所見 Are there any physical or mental conditions that may limit the student's ability to study? □ 有 Yes □ 無 No 有の場合、具体的に症状を記入してください。 If "Yes", please describe the conditions in detail. 食物・薬物アレルギーがあれば記入してください。 Does the student have any food or drug allegies? If "Yes", please describe. この学生は精神的及び身体的に、海外での留学に適した状態にあるとお考えになりますか? Do you consider the student to be in adequate mental and physical health for full and sucessful participation in the study abraod program? □ はい Yes □ いいえ No いいえの場合、具体的な理由を述べてしてください。 If "No", please describe the reason. 診断日 Date 医療機関名 Institution/Clinic 所在地 Address 医療機関印 Official Stamp of Institution/ Clinic 医師氏名 Name of Physician 署名 Signature 2011.01 東 北 大 学 Tohoku University, Student Exchange Division 41 Kawauchi, Aoba-ku, Sendai, 980-8576 Japan Tel: +81-22-795-7820 Fax: +81-22-795-7826 E-mail: [email protected] http://www.tohoku.ac.jp CERTIFICATE OF HEALTH Applicant’s name: (Family) (Given) (Middle) Sex: □Male Date of birth: (Month) Height: ( ) cm Weight: ( ) kg Sight: Uncorrected: Corrected: Hearing: Urinalysis: Right ( Albumin ( (Day) Right ( Right ( ) ) ) Left ( Left ( Left ( ) □Female (Year) ) ) ) Sugar ( ) Occult Blood ( ) Respiratory Organs: Chest X-ray: Please comment on condition of applicant’s lungs, giving date of examination. Circulatory Organs: Blood Pressure: Systolic ( ) Diastolic ( ) P.R. ( ) p.m. Nervous System: Please give a detailed description of any disease, including chronic ailments or physical disabilities, found. Please give the applicant’s medical history. Is the general state of the applicant’s health good enough for him/her to pursue the course of study contemplated in Japan? □Excellent □With prudence, probably no serious problem □Adequate □Doubtful Signature: (Name in block) Position: Date: SAMPLE FORM FOR CIEE PROGRAMS IN SENEGAL AND TANZANIA Malaria Contract Addendum (Africa) This form is important. All Senegal and Tanzania participants must sign this form. Name (please print): Program: Term(s) – check all that apply: ○ Senegal ○ 2012 Spring ○ Tanzania ○ 2012 Fall ○ Other: Consent and Commitment to Utilization of Prophylactics against Malaria Malaria is endemic in Senegal and Tanzania. Unless malaria prophylactics are taken faithfully as prescribed there is a significant risk of contacting a serious or fatal disease. Consequently, CIEE will not accept you or retain you in this program if you do not agree to take anti-malaria medication as prescribed. The only exception to this rule is if you produce a statement from your doctor prior to the commencement of this program that, for other medical reasons, your doctor recommends against your taking any malaria prophylactic. Please sign the form below and return it to us with your application materials. I agree to take prophylactic anti-malaria medication regularly as prescribed unless prior to the beginning of the program, I submit to CIEE a statement from my doctor recommending against my taking said medication. Signature of Participant Date Signature of parent of guardian of participant if participant is under the age of majority in the jurisdiction where this document is signed. Date CIEE – Supplemental Medical Release Form This Medical Release form is supplemental and not in substitution of the CIEE Student Medical Form which I signed on or about ____________. I am voluntarily opting to study abroad in Dakar, Senegal although I have disclosed that I have a serious allergy to peanuts. I understand that peanuts and/or their derivatives are used in virtually all Senegalese dishes. I agree to release CIEE from any liability for any medical issues or other problems that may result from this allergy during my time on the CIEE Dakar Language and Culture program. Further, I understand that CIEE will not be able to guarantee a peanutfree environment or peanut-free meals during my time on the program. I understand that health issues stemming from my peanut allergy must not interfere with attendance in classes or with my participation in any CIEE obligatory and optional events and understand and accept that CIEE has the right to dismiss me from the program at any time if my allergy results in health issues or related problems that require significant on-going care by CIEE resident staff and my CIEE homestay family. Student Name: __________________________ Student Signature: _______________________ Date: _________________________________ SINGAPORE - Year Students Only MEDICAL EXAMINATION REPORT For New Applicants: 1. The Medical Examination may be done in Singapore by any registered General Practitioner (GP). Applicants who are in their home countries/places of residence may have their Medical Examination and HIV test done in their home countries/places of residence at any medical clinic licensed to carry out such tests. If HIV testing is done in Singapore, it may be carried out with either rapid or ELISA tests. For Renewal Applicants: 1. The Medical Examination MUST be done in Singapore by any registered GP. HIV testing may be done with either rapid or ELISA tests. Notes for All: 1. This Medical Examination Report is to be completed by a registered doctor and returned to the examinee. The original copy of the laboratory report for HIV and the X-ray report must be attached to this Medical Examination Report only if the medical examination and testing is carried out overseas. 2. The laboratory report for HIV and the X-ray report submitted to the Immigration & Checkpoints Authority should be within THREE MONTHS from the date of the issue of the reports. I Personal Particulars 1. Name (as in the passport): 2. Sex: M / F 3. Date of Birth : 4. Nationality : 5. Passport No. : 6. FIN No. (if applicable) : 7. Address in Singapore: II Medical Examination I certify that the above-named has undergone a chest x-ray and the result of his/her chest X-ray is as indicated (with a [√]):Yes No 1. TB (Chest X-ray)* Any evidence of active TB detected? [*Pregnant Women are exempted from Chest X-Ray] I certify that I have tested the above-named and the result of his/her HIV test is indicated below (with a tick [√]). Positive Negative/Non-Reactive 2. HIV : Name of Examining Doctor (IN BLOCK LETTERS): Signature : Clinic’s Stamp & Address: Date: Telephone Number : MCR no: _______________________ NOTE: For persons screened overseas, the name in the laboratory report for HIV and the X-ray report must be according to the name shown in the Passport. DECLARATION I, declare that the above is not applicable to me as (name) I have submitted a medical report** containing the above information to Immigration & Checkpoints Authority / Ministry of Manpower*** (not more than two years ago) when I was granted the (pass type) on valid till (dd/mm/yy) . (dd/mm/yy) Signature & Date ** Those who were previously exempted from submitting the X-ray report because of pregnancy are required to submit a X-ray report certified by a Singapore registered GP, if you are not pregnant now. *** Delete where necessary. WARNING: Version 4 (4 Oct 07) IT IS AN OFFENCE UNDER THE IMMIGRATION ACT TO MAKE ANY FALSE STATEMENT, REPRESENTATION OR DECLARATION BI-806 G.P.-S. 017-0044 REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS RADIOLOGICAL REPORT Note: (1) A radiological report of the chest is required in respect of every prospective immigrant 12 years of age and over. (2) The radiologist must insert the names of the prospective immigrants examined by him in the space provided for that purpose on the form. Unused spaces must be crossed out. (3) A separate report is required in respect of every applicant suffering or suspected to be suffering from tuberculosis. I hereby certify that I have radiologically examined the chest(s) of the following person(s) and that I could find no signs of active pulmonary tuberculosis. Name: (1) ________________________________________________________________________________ (2) ________________________________________________________________________________ (3) ________________________________________________________________________________ (4) ________________________________________________________________________________ (5) ________________________________________________________________________________ (6) ________________________________________________________________________________ _____________________________________ Radiologist Official stamp and address of Radiologist/Hospital: Date: ________________________________ ____________________________________________ ____________________________________________ ____________________________________________ UNIVERSITYWIDE OFFICE of the EDUCATION ABROAD PROGRAM (UOEAP) SPAIN: Required Medical Certificate Only for stays over 180 days REQUIRED: • The original medical certificate must be: 1. translated into Spanish (see below) plus one (1) copy; 2. issued on a doctor or medical center letterhead, 3. signed by a physician (MD or DO). A stamped signature will not be accepted. The certificate must bear the official stamp of the administering center; however, the stamp will not be regarded as a substitute for the doctor’s signature. 4. issued in the place of residence • • • The certificate is valid for three months counting from the date it is issued. The doctor must certify that the student does not suffer from any illness that would pose a threat to public health according to WHO IHR 2005. Any amendment to the certificate or erasure may render it invalid. Text This medical certificate attests that Mr. / Ms. ……………………… does not suffer from any illness that would pose a threat to public health according to the International Health Regulations of 2005. Signature Date Este certificado médico acredita que el Sr./Srta……………………….. no padece ninguna de las enfermedades que pueden tener repercusiones de salud pública graves de conformidad con lo dispuesto en el Reglamento Sanitario Internacional del 2005. Firma Page 1 of 1 Fecha 1/6/2010 NTU Health Exam Requirement for Incoming Exchange / Visiting Students In order to understand the general health condition of coming students, and to meet the regulations of National Taiwan University, all students should receive a health exam by a qualified physician. The registration procedure is not complete if the new student does not have her/his health exam form completed. For convenience, you may take the health exam abroad, as long as all items are completed and the examination form includes the doctor’s signature and stamp of the hospital or clinic (for certification), and is no longer than 3 month old. You may download the health exam form from the OIA website at http://www.oia.ntu.edu.tw/ex-in/2_apply.asp and bring it to the hospital. The required items are included in the “NTU General Health Exam Form”. Most importantly, please remember to bring the completed exam form with you when registering at NTU. ※ Special instructions 1. Please inform the doctor if you are pregnant. (You are allowed to skip the CXR exam when you are pregnant.) 2. Please avoid checking your urine when menstruating. 3. Fasting at least for 8 hours is indicated for laboratory tests. 1 國立臺灣大學交換暨訪問學生一般體格檢查表 NTU Incoming Exchange / Visiting Students Health Exam Form 姓名 Name 性別 Sex: □ 男 Male □ 女 Female 生日Date of Birth: 年Y/ 月M / 日D國籍Nationality: 居留證或護照號碼 ARC or Passport No.: 系所 Department : 相片 Photo 學號 Student ID: 個人病史 Personal History ) □食物 Food allergies 或 □藥物過敏 Drug allergies (名稱 Item name: 理學檢查 身高 Height: cm Physical Examination 體重 Weight: 血壓 Blood Pressure: kg 腰圍 Waist circumference: mmHg ／ 脈搏 Pulse Rate: 皮膚 Skin: 頭頸部 Head & Neck: 胸部 Chest: 肺部 Lungs: 腹部 Abdomen: 心臟 Heart: 口腔 Oral Cavity: 其他 Others: cm /min 肌肉、骨、關節 Muscles/Bones/Joints: 視力 Visual Acuity: 裸視 Uncorrected （R L 辨色力 Color Differentiation: □無異常 Normal □異常 Abnormal ） 矯正 Corrected （R L ） 聽力 Hearing: 右 Right □通過 Pass □未通過 Fail / 左 Left □通過 Pass □未通過 Fail 實驗室檢查 肝功能 ALT: U/L Laboratory Examinations 空腹血糖 AC sugar: mg/dL 白血球數 WBC: K/μL mg/dL 血紅素 Hb: g/dL 肌酸酐 Creatinine: mg/dL 尿酸 Uric acid: 總膽固醇 T-cholesterol: mg/dL 三酸甘油脂 Triglycerides: 尿液 Urine: 尿蛋白 Protein 尿糖 Sugar mg/dL 血小板數 Platelet: K/μL 尿潛血 Fecal Occult Blood 胸部Ｘ光 Chest X-Ray（限大片 Standard Film Only）: 個案目前是否因疾病服用藥物或接受治療 Is the student taking medications or treatment for any disease: 總評及建議 Comments and Suggestions: 醫師簽章Doctor’s signature: 證書字號Professional Identification number: 檢查日期Date of health exam: 體檢醫療院所名稱 Name of the medical institution for the health exam: 請務必加蓋機關印章，否則視同無效。Not valid if without the institution’s seal. ※ 醫師理學評估檢查、胸部 X 光檢查為必要項目( Physical exam by physicians and Chest X-ray exam are mandatory items) 2 SAMPLE FORM FOR CIEE PROGRAMS IN SENEGAL AND TANZANIA Malaria Contract Addendum (Africa) This form is important. All Senegal and Tanzania participants must sign this form. Name (please print): Program: Term(s) – check all that apply: ○ Senegal ○ 2012 Spring ○ Tanzania ○ 2012 Fall ○ Other: Consent and Commitment to Utilization of Prophylactics against Malaria Malaria is endemic in Senegal and Tanzania. Unless malaria prophylactics are taken faithfully as prescribed there is a significant risk of contacting a serious or fatal disease. Consequently, CIEE will not accept you or retain you in this program if you do not agree to take anti-malaria medication as prescribed. The only exception to this rule is if you produce a statement from your doctor prior to the commencement of this program that, for other medical reasons, your doctor recommends against your taking any malaria prophylactic. Please sign the form below and return it to us with your application materials. I agree to take prophylactic anti-malaria medication regularly as prescribed unless prior to the beginning of the program, I submit to CIEE a statement from my doctor recommending against my taking said medication. Signature of Participant Date Signature of parent of guardian of participant if participant is under the age of majority in the jurisdiction where this document is signed. Date
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