International Immunization and Health Questionnaire Patient InformationName(Required) First Middle Surname Student ID Number(Required)University Email(Required) Sex(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY US Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneDo you live on campus?(Required) Yes No Semester first enrolled at SAUPlease enter the Term and Year you were first enrolled at SAU. Examples: Fall 2022What residence hall and room number do you live in on-campus?(Required)Insurance InformationAre you planning on getting the LewerMark Insurance provided by the school?(Required) Yes No Are you currently covered by a private policy or on spouse's insurance?(Required) Yes No What is the carrier name of your current health insurance?(Required)What is the insurance policy number?(Required)Proof of Insurance Information(Required) Drop files here or Select files Max. file size: 12 MB. Please upload a copy or image of your current insurance card.Medical HistoryBecause the University is interested in providing a good learning environment for students, it is helpful to know of factors that could affect the accommodations made by the University for adjusting to the special needs of students.Have you ever received a MMR vaccine? (Measles/Mumps/Rubella)(Required) Yes No Date of first MMR vaccine(Required) MM slash DD slash YYYY Have you received a second dose of the MMR vaccine? (Measles/Mumps/Rubella)(Required) Yes No Date of second MMR vaccine (if received)(Required) MM slash DD slash YYYY If you have not received your second MMR vaccine, please leave this field blank.Do you have proof you can upload of your first and/or second MMR vaccine?(Required) Yes No Proof of MMR vaccine(s)(Required) Drop files here or Select files Max. file size: 12 MB. Please upload any images of your MMR vaccine card or documentation for your first and/or second shot. TSPOT QuestionnaireWhat country are you from?(Required)AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsWhen did you arrive to the US?(Required) MM slash DD slash YYYY Where do you live now?(Required)SAU Immunization RequirementsSouthern Arkansas University requires the following to be completed within 45 days of starting classes. This regulation is strongly enforced by the Arkansas Department of Health. T-Spot test or Quantiferon TB Gold test - (TB skin tests are NOT accepted) 2 doses of MMR vaccine (Mumps, Measles, and Rubella) In the last 6 months have you had a T-Spot or Quantiferon Gold TB test? If so please provide proof in the file upload field below.(Required) Yes No Recent T-Spot Test Results(Required) Drop files here or Select files Max. file size: 12 MB. If you have had a T-Spot test within the last 6 months, please an image of the documentation here.Patient's Agreement to Immunization Information Sheet(Required) I have reviewed the immunization information and understand that it is my responsibility to get all three requirements fulfilled by the deadline set by University Health Services. If I fail to do so I understand that I will be held responsible and could face disciplinary actions that result in termination from Southern Arkansas University.Patient's Consent for Treatment(Required) I am suffering from a condition requiring University Health Services care and do herby voluntarily consent to such care encompassing routine diagnostic procedures and medical treatment by a physician, as is necessary in his/her judgement. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examination in the infirmary. This form has been fully explained to me and I certify that I understand its contents. I have executed this consent, intending to be legally bound thereby.Missing items(Required) First MMR Second MMR T-Spot Chest X-Ray Nothing Missing, Student Complete Δ
