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CERTIFICATE OF HEALTH
THIS FORM IS TO BE COMPLETED AND RETURNED TO GARDEN CITY COMMUNITY COLLEGE TO ALLOW ENROLLMENT
(Finney County students take this form to Finney Co. Health Dept. for completion.)
The above student has been referred for TB testing and any follow up treatment as indicated. Upon completion of testing and appropriate
treatment, as documented by health care personnel below, the student will return this form to GCCC to allow enrollment.
Tuberculin Skin Test (TST) (Mantoux/PPD documented in millimeters of induration)
DATE GIVEN____/____/______ GIVEN BY________________________________________________
DATE READ____/____/_______ READ BY_________________________________________________
RESULT:______MM OF INDURATION INTERPRETATION: negative______ positive_______
------------------------------------------------------------------------------------OR------------------------------------------------------------------------------------------------------
Interferon Gamma Release Assay Blood Test (IGRA)
DATE OBTAINED_____/_____/_______ SPECIFY METHOD: _____QT _____OTHER
RESULT: negative_______ positive_______ intermediate_______
Signature of health care provider completing blood test_________________________________________________________
It will be the student’s responsibility to pay for all services not covered by insurance at the time they are received.
To the best of my knowledge, the information provided above is accurate and complete. I am aware that misrepresentation of information could result in
dismissal from classes at GCCC and may jeopardize my health. I agree to complete any indicated and required evaluation and treatment to be allowed enrollment
and attendance at Garden City Community College.
By signing this form, I agree to allow communication between Finney County Health Department or other health care entities outside Finney County involved in
my medical care relating to the implementation of the TB Risk Assessment Law (Kansas Statute KSA 2009 Supp. 65-129) and Garden City Community College.
Student Signature_________________________________________________________Date_______________________________
IF EITHER OF THE ABOVE TB TESTS ARE POSITIVE OR INDETERMINATE OR YOU HAVE HAD A PREVIOUS REACTION TO TB TESTING, YOU WILL BE REQUIRED TO
OBTAIN A CHEST X-RAY.
DATE OF CHEST X-RAY:______/______/______ RESULT: normal___________ abnormal_______________
IF CHEST X-RAY RESULTS ARE ABNORMAL, FURTHER EVALUATION AND TREATMENT WILL BE REQUIRED BEFORE ENROLLMENT AT GCCC.
This box is to be completed by a representative of Finney County Health Department. If you have obtained testing outside of Finney County,
the appropriate health care provider will complete the information below. This completed area will allow enrollment at GCCC.
The above individual has received all required evaluations and treatments indicated and is cleared to enroll at Garden City
Community College.
SIGNATURE OF HEALTH CARE PROVIDER__________________________________________________________ DATE _______________________________
__________________________________________________________ ______________________________
PRACTICE SITE PHONE NUMBER
STUDENT INFORMATION (To be completed by student) (Please print)
Last Name:_________________________________ First name:__________________________________ GCCC Student ID:_______________
Date of birth: _________________ Phone number:_______________________ Address:___________________________________________
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