We join others in welcoming you to Carleton College. As part of our effort to provide quality health care to Carleton students, we ask that you take time to PRINT and thoroughly complete this Report of Medical History Form (physical examination required in the past 6 months). Having this information readily available allows us to provide for your ongoing health care needs, as well as emergency medical treatment. Please return this completed form by August 6, 2009. This will allow us time to review your records and insure that your registration will not be delayed.

We would particularly like to draw your attention to the section on immunizations:

To be compliant with Minnesota State Law, all incoming students are required to submit:

• dates of immunization against tetanus and diphtheria (Td) or Tdap (must have had Td/Tdap within the past 10 years)
• dates of immunizations against measles, mumps, rubella (MMR) (need evidence of 2 doses of MMR)
• a completed Tuberculosis Risk Assessment on page 5 and if indicated, submit results of a PPD (Mantoux test) within the past 6 months
• International Students must provide results of a TB mantoux test given within the last 6 months

We and the American College Health Association also strongly recommend:

• Hepatitis A/B series: www.immunize.org/catg.d/p4075abc.pdf
• influenza vaccine clinic will be held on October 27, 2009 on campus.
• meningitis vaccine (a brochure will be in your post office box on campus when you arrive) (preferably Menactra, but menamune is acceptable if conjugate menactra not available)
• varicella (chicken pox) vaccine for those without history of disease (2 doses of vaccine)
• HPV (see Wellness Center website –click on HPV vaccine for info)

We encourage you to discuss these vaccinations with your home medical provider during your appointment for your college entrance medical examination.

For students planning to participate in NCAA sports:

Please review and sign the release of information on the bottom of page 8. This will allow The Carleton College Wellness Center providers and athletic trainers to share your health information as needed, and not delay your start of practice schedule.

Students who have not turned in a completed Report of Medical History form and provided dates of Td or Tdap, MMR immunizations and mantoux test (if required) will not be allowed to register for winter term classes.

The Wellness Center is closed the month of July. If necessary, contact us before or after July by phone (507) 222-4080, by e-mail at: Wellness@carleton.edu or for additional information view The Wellness Center website.

Report of Medical History Form Due By August 6, 2009

Disability Information

It is the policy of Carleton College to create and maintain an environment in which all students may learn and work to their fullest potential. We strive to assist and accommodate students with disabilities. Positive communication and early disclosure of disabilities are key components for success. In the green box on the right hand side of this page is a link to the Disability Self Disclosure - Provider Verification Form. If you have documented evidence of a disability for which you seek accommodation, please answer the questions on this form and attach the appropriate documentation. This information will then be evaluated and appropriate accommodations will be determined. Completion of the Disability Self Disclosure - Provider Verification Form does not guarantee accommodations. We urge you to submit documentation by June 1, 2009 so appropriate accommodations can be determined prior to fall term.

Student Insurance

Carleton College is interested in the health and welfare of our students. Consequently, we require all enrolled students to have health insurance. Two options exist for you in securing health insurance. We require one of the following: 1. You may continue coverage that you currently have through your family (You must complete a waiver form) or 2. You may purchase insurance though the College (You must complete an enrollment form.) For more Enroll or waive College insurance, please visit the Collegiate Insurance Resources website. For more information about the College Insurance, please visit the Carleton Student Insurance website.

The Wellness Center is closed the month of July. If necessary, contact us before or after July by phone (507) 222-4080, by e-mail at: Wellness@carleton.edu or for additional information view The Wellness Center website.