Fillable Student Health Information Form (North Central Kansas Technical College)

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Student Health Information Form (North Central Kansas Technical College)

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North Central Kansas Technical College
Beloit Campus Hays Campus
P.O. Box 507 | 3033 U.S. Highway 24 | Beloit, Kansas 67420 2205 Wheatland Ave. | Hays, Kansas 67601
1-800-658-4655 | 785-738-2276 1-888-567-4297 | 785-625-2437
ncktc.edu
Student Health Information Form
(To be completed by all students before class attendance at North Central Kansas Technical College)
Pe
rsonal Information:
__________________________________ ________________________________________ ________
First Name Last Name MI
________________ _________________ ______________________ ___________________________
Campus Student ID Email Address Phone Number
______________________________________________ _________________ ________ ___________
Permanent Address City State Zip Code
Immunization History:
Please list the dates of each immunization. Please put N/A as Not Applicable.
Tetanus: _______________________
Measles/Mumps/Rubella 1 (MMR1): _________________
Measles/Mumps/Rubella 2 (MMR2): _________________
Meningitis 1: ____________________ (The meningitis shot or waiver is mandatory to live in student housing)
Meningitis 2: ____________________ (The meningitis shot or waiver is mandatory to live in student housing)
Hepatitis 1 (HepB1): ____________________
Hepatitis 2 (HepB2): ____________________
Hepatitis 3 (HepB3): ____________________
Tub
erculosis Screening History:
Tuberculosis, also known as TB, is a bacterial infection that attacks the lungs and, sometimes, other parts of the body. It is spread
when someone infected with the disease coughs or sneezes and the bacteria is inhaled by someone nearby.
North Central Kansas Technical College requires ALL students to complete a Tuberculosis Screening Questionnaire, per Kansas
Statute KSA 2009 Supp. 65-129 to aid in prevention and control of Tuberculosis as required by State of Kansas Department of
Health & Environment.
Return this form to the NCKTC Student Experience Office prior the first day of class. Fax: 785-738-2903. Phone: 785-738-
9075 or e-mail sbritt@ncktc.edu
If further testing is indicated, the process could take up to 4 weeks to complete. DO NOT WAIT UNTIL THE LAST
MOMENT to avoid being dropped from your classes.
For additional information on TB: www.cdc.gov/tb/publications/factsheets/default.htm
North Central Kansas Technical College
Beloit Campus Hays Campus
P.O. Box 507 | 3033 U.S. Highway 24 | Beloit, Kansas 67420 2205 Wheatland Ave. | Hays, Kansas 67601
1-800-658-4655 | 785-738-2276 1-888-567-4297 | 785-625-2437
ncktc.edu
PLEASE CHECK YES OR NO TO THE FOLLOWING QUESTIONS:
1. Have you ever had a tuberculosis (TB) test that was positive? YES_____ NO_____
2. Have you ever received the BCG vaccine, which is given outside the United States, to prevent tuberculosis (TB)?
YES_____ NO_____
3. Have you been in contact with anyone who was sick with tuberculosis (TB) in the last 3 months?
YES_____ NO_____
4. Were you born in a country not on the list below? (Country of birth) ______________________________
YES_____ NO_____
5. Have you ever spent more than 3 months in a country not on the list below? YES_____ NO_____
Please list the country _______________________________.
LIST OF EXEMPT COUNTRIES WITH LOW INCIDENCE OF TB
(Defined by the Kansas Department of Health & Environment)
Albania Canada Germany Nauru Sweden
American Samoa Chile Greece Netherlands Switzerland
Andora Costa Rica Grenada New Zealand Turks & Caicos Islands
Antigua & Barbuda Cyprus Hungary Norway United Kingdom of Great
Australia Czech Republic Iceland Saint Kitts & Nevis Britain & North Ireland
Austria Denmark Ireland Saint Lucia United States Virgin Islands
Bahamas Dominica Italy Samoa United States of America
Barbados Fiji Jamaica Slovakia Wallis & Futuna Islands
Belgium Finland Luxembourg Slovenia
British Virgin Islands France Malta Spain
If you answered yes to any of the above questions, you are required to provide documentation of further testing and evaluation by a
health care provider before enrollment of classes at NCK Tech.
1. You will be required to undergo a TB blood test instead of a TB skin test, if you:
* Were born in a country not on the above list.
* Have received the BCG vaccination.
2. If you have had a past positive TB test, you will need to go to a healthcare provider for a signs/symptoms check and complete any
testing required. You will need to present documentation of such to enroll.
3. If you have received prior treatment for any TB disease, you will need to provide proper documentation of treatment protocol and
completion. (Can be obtained from the physician providing care). Submit prior to enrollment.
All tests can be obtained at a County Health Department or your local health care provider before the first day of class.
Trave
l History:
If you have lived or spent time overseas, list the countries:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
North Central Kansas Technical College
Beloit Campus Hays Campus
P.O. Box 507 | 3033 U.S. Highway 24 | Beloit, Kansas 67420 2205 Wheatland Ave. | Hays, Kansas 67601
1-800-658-4655 | 785-738-2276 1-888-567-4297 | 785-625-2437
ncktc.edu
Health History:
Please select all that are current or past problems:
___ Allergies: _____________________ ___ Gastric ___ Nervousness
___ Anemia ___ Heart Trouble ___ Positive PPD
___ Back Injuries ___ Hepatitis A ___ Rheumatic
___ Boils ___ Hepatitis B ___ Scarlet
___ Cancer ___ Hernia ___ Skeletal
___ Chicken Pox ___ Hypertension ___ Surgical
___ Convulsions ___ Kidney ___ Tuberculosis
___ Diabetes ___ Menstrual ___ Varicosities
___ Dizziness ___ Mental Other______________________________
___ Epilepsy ___ Migraine Other _____________________________
M
eningococcal Vaccine Waiver:
It is the policy of the Board of Regents of the State of Kansas that incoming students residing in student housing be vaccinated for
meningitis or sign a waiver refusing receipt of the meningitis vaccine. This form is provided by North Central Kansas Technical
College to students wanting to waive the Meningococcal Vaccine. If you decide to waive the Meningococcal Vaccine, you must print
this form, sign and return it to NCK Tech Student Experience Office.
Please read the Centers for Disease Control educational material regarding the hazards and risks of meningitis disease and the
meningococcal vaccine at www.cdc.gov/vaccines. Complete this form and return to Student Experience Office, PPO Box 507, Beloit,
KS 67420. This information is confidential and shall be used by NCK Tech to track compliance with the current Meningococcal
Vaccine policy.
WAIVER: I have read the educational information referred to me in this form about the risks of contracting meningitis and have
refused the vaccination.
Student Initials:_____________________ Date(MM/DD/YYYY):_______________
S
tudent Acknowledgement __________________________________________________ Date: ______________________
T
o the best of my knowledge, the information provided above is true and complete. I am aware that deliberate misrepresentation may
jeopardize my health and enrollment status.
I
f a student is under the age of eighteen (18), signature of a parent or legal guardian:
P
arent or legal guardian’s acknowledgement: ____________________________________ Date: _______________________
T
o the best of my knowledge, the information provided above is true and complete. Any student who is not in compliance with the
requirements shall not be attending classes or eligible to enroll for a subsequent semester or term or to obtain an official academic
transcript or diploma until the student is compliant per Kansas Statute KSA 2009 Supp. 65-129.
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Completed 26 July 2020

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