Ccad.edu

MEDICAL INFORMATION FORM
STUDENT AFFAIRS OFFICE, COLUMBUS COLLEGE OF ART & DESIGN – The medical information forms (pages 1–3) are to be completed and signed by the student (or parent/guardian if appropriate).
– All immunizations (page 4) must be up to date and the form signed All students MUST SUBMIT this form and immunization records. Enrollment for by a health care professional. Official print-outs from health care next semester will not be permitted if you lack proof of mandatory vaccinations.
providers may be attached to the form in place of the signature.
Please be aware that the College does not provide on-campus medical services. – If faxed from physician’s office, please check that all mandatory A physical examination, WHILE NOT MANDATORY, is highly recommended as a immunizations as listed are current.
vital supplement to your health history.
– All information must be provided in English.
Important: This form DOES NOT serve as official notification to the College of a disability for purposes of ADA or Section 504 of the Rehabilitation Act. – Students seeking a medical/religious exemption to providing this If accommodations are requested, official documentation must be filed with information must contact the Student Affairs Office at 614.222.4044.
Disability Services. Call 614.222.4004 for more information.
– Please make a copy of this record for your own files. Medical forms will be held by CCAD for only 6 years from the date a student enters the college. After that, the medical form will be destroyed and no copies will be available.
STUDENT INFORMATION (PLEASE PRINT CLEARLY) MEDICAL INFORMATION FORM (CONTINUED)
I GIVE PERMISSION FOR HEALTH CARE PROVIDERS TO ADMINISTER ANY MEDICAL OR DENTAL PROCEDURES Parent or guardian must sign if student is under 18 years old. In the event of serious illness or injury, every effort will be made to contact parent/guardian.
A physical examination, while not mandatory, is highly recommended as a vital supplement to your health history. We find that a physical exam prior to the beginning of classes can help ensure a semester uninterrupted by absences due to illness. Including a copy of your physical examination report when you return these health documents is helpful to the College in the event of an emergency or other medical situation.
MEDICAL INFORMATION FORM (CONTINUED)
MEDICAL INFORMATION Please indicate whether or not you have experienced or been treated for any of the following (past or present).
Mood stabilizers (Lithium, Abilify, etc.) Inhaler for asthma or other breathing condition PLEASE CHECK IF YOU WILL NEED ANY OF THE FOLLOWING WHEN YOU ENTER COLLEGE: HAVE YOU CONSULTED OR BEEN TREATED BY A PSYCHIATRIST, CLINICAL PSYCHOLOGIST, OR COUNSELOR? IF YOU HAVE BEEN HOSPITALIZED OR HAVE ANY MEDICAL PROBLEMS, PLEASE GIVE DETAILS MEDICAL INFORMATION FORM (CONTINUED)
PLEASE READ THIS FORM CAREFULLY AND PAY ATTENTION TO WHAT IS REQUIRED VERSUS WHAT IS OPTIONAL.
CCAD requires all students to show proof of vaccination against Measles, Mumps, and Rubella (MMR), Tetanus (within last 5 years), and Hepatitis B (a series of 2–3 injections). If none of the Hepatitis B series shots have been received prior to entering school, documentation of the first injection along with the dates of your appointments for the second and third must be submitted with this form. Meningitis vaccination and a Tuberculosis test are highly recommended, especially if you will be living in a residence hall environment. If documentation is not available for any vaccinations, you will need to have titer levels checked with your doctor and provide that documentation. These requirements, although time consuming, are necessary for everyone’s protection. If faxed from your physician’s office, please check that all mandatory immunizations as listed below are current.
Please do not wait until the last minute to schedule your necessary vaccinations.
You will not be permitted to enroll for the next semester if you lack proof of mandatory vaccinations.
MAKE A COPY OF THIS PAGE FOR YOUR OWN RECORDS. CCAD will only maintain this record for 6 years from the time a student enters the College. After that, it will be destroyed.
SEMESTER ENTERING CCAD (FALL/SPRING, YEAR) TETANUS/DIPHTHERIA (MUST BE WITHIN LAST 5 YEARS) (MM/DD/YY) MANTOUX TEST FOR TB: DATE OF TEST (MM/DD/YY) IF TB TEST IS POSITIVE: CHEST X-RAY REPORT (CHECK ONE): IF CHEST X-RAY IS POSITIVE EXPLAIN TREATMENT OFFICIAL PRINT-OUTS FROM HEALTH CARE PROVIDERS MAY BE SUBMITTED ATTACHED TO THIS FORM IN PLACE OF THE SIGNATURE BELOW. SIGNATURE OF DOCTOR (OR OTHER PROFESSIONAL HEALTH CARE PROVIDER)

Source: https://www.ccad.edu/files/student-services/counseling/undergrad-medical-info.pdf