GEORGIA INSTITUTE OF TECHNOLOGY

MEDICAL ENTRANCE FORM (REQUIRED)

Please fax your completed form to 404-385-0329

Today’s date: _______________GT ID#: ___________________________ Birth Date: ______________ Age at time of Application: ___________
Name (Last, First, Middle) ________________________________________________________________________________________________
Address: ___________________________________ City:_____________________ State: _____________ Country: ______________________
Zip Code: ______________ Cell Phone #: ___________________________ Email:___________________________________________________
1. ALLERGIES (List all drug, food, insect or other known allergies below)
___________________________________________________________________________________________________________________
Allergy shots YES NO If yes, please give specific details: ___________________________________________________
2. HOSPITALIZATION (List all hospitalizations, dates and reasons)
___________________________________________________________________________________________________________________
3. MEDICATION (List all medications you are currently taking)
___________________________________________________________________________________________________________________
4. MEDICAL CONDITION
Do you have a chronic (long-lasting or persistent) medical condition that requires treatment or medication? YES NO
If yes, please have your physician send a summary of your treatment that includes the following: (condition being treated, type of medicine and
physician’s address and phone number)

5. AUTHORIZATION TO TREAT (If you are over 18 years of age)

I hereby authorize the physicians of Stamps Health Services and their agents or consultants, including those at area hospitals, to
perform diagnostic and treatment procedures which in their judgment may be necessary while I am at Georgia Tech.

Signature: ____________________________________________ Date: ________________

MMDDYYYY

AUTHORIZATION TO TREAT (If you are under 18 years of age)

I hereby authorize the physicians of Stamps Health Services and their agents or consultants, including those at area hospitals, to
perform diagnostic, preventative, and treatment procedures which in their judgment may be necessary while she/he attends Georgia
Tech. I waive all claim to prior notification. I understand that every effort will be made to notify me in the event of a major illness or
injury, or if the Stamps Health Services physician feels it is necessary.

Signature of parent/guardian: ____________________________________ Date: ____________

Name: ____________________________________ Relationship: _______________________
Address: ___________________________________________________________________________________________________________
City: __________________________________ State: _________________ Country: ____________________ Zip Code: _____________

Daytime phone: _________________ Evening phone: _________________ Email: __________________________________

Name: ____________________________________ Relationship: _______________________

Address: ___________________________________________________________________________________________________________
City: __________________________________ State: _________________ Country: ____________________ Zip Code: _____________

Daytime phone: _________________ Evening phone: _________________ Email: __________________________________

 GEORGIA INSTITUTE OF TECHNOLOGY

CERTIFICATE OF IMMUNIZATION
PLEASE FAX COMPLETED FORMS TO 404-385-0329. RETAIN A COPY OF THE COMPLETED FORM FOR YOUR RECORDS.

Name (Last, First, Middle) _________________________________________________________________________________________________

GTID#: ______________ Birth date: ___________ Cell Phone#: ______________ Email: ______________________________________________

REQUIRED
REQUIRED IMMUNIZATIONS REQUIREMENT (MMDDYY) REQUIRED FOR:
MMR (Measles, Mumps, Rubella) 2 Doses # 1 ____________ #2 __________ • Students born in 1957 or later
• 1st due at 12 months of age or older
• 2nd dose due at 4-6 years of age or older
OR OR
• Measles (Rubeola) 2 Doses # 1 __________ #2 __________ • Students born in 1957 or later
Or Titer __________
AND AND
• Students born in 1957 or later
• Mumps
2 Doses # 1 __________ #2 __________
Or Titer __________
AND AND
• Rubella (German Measles) 1 Dose # 1 __________ • Students born in 1957 or later
• Attach titer results if done
Or Titer __________
Varicella (Chicken Pox) 2 Doses # 1 __________ #2 __________ • All US born students born in 1980 or later and
Or all foreign born students regardless of year born.
(Previous history of chicken pox Or Titer __________ • Attach titer results if done
not accepted)

Tetanus and Diphtheria (Td or Td __________ • All Students must have one dose within 10
Tdap) years
Tdap __________

Hepatitis B or Hep A-Hep B 3 Doses # 1 __________ #2 __________ • All Students

combination (Please circle one) # 3 __________
Tuberculosis screening • Must complete TB assessment questionnaire. • All students, with risk noted, must complete
the TB skin testing form.
RECOMMENDED (MMDDYY)
Gardasil (HPV) 3 Doses # 1 ____________ #2 _____________ #3 _____________
Hepatitis A
2 Doses # 1 ____________ #2 _____________
Meningitis (MCV4) 1 Dose # 1 ____________
Pneuomvax 1 Dose # 1 ____________
REQUEST FOR IMMUNIZATION EXEMPTION
 Temporary medical  Permanent medical  Religious exemption.  I declare that I will be enrolling in ONLY courses offered
exemption until ____________ exemption. Attach Attach verification by by distance learning. I understand that if I register for a
Attach verification by doctor verification by doctor on religious leader on church course that is offered on-campus or at a campus managed
on letterhead. letterhead. letterhead. facility this exemption becomes void and I will be excluded
from classes until I provide proof of immunization.
REQUIRED SIGNATURE OF HEALTH CARE PROVIDER
Name: _____________________________________
Signature: _____________________________________
PHYSICAN OFFICE STAMP
Phone: ____________________ Date: _____________
 GEORGIA INSTITUTE OF TECHNOLOGY
TUBERCULOSIS ASSESSMENT FORM (REQUIRED)
PLEASE FAX COMPLETED FORMS TO 404-385-0329. RETAIN A COPY OF THE COMPLETED FORM FOR YOUR RECORDS.

Date: ____________ GTID#: ____________Birth Date: ____________ Email:________________________________________

Name (Last, First, Middle) ___________________________________________________________________________________
Address: __________________________________________________________________________________________________
City: ________________________State: ____________ Country: _____________________________Zip Code: ____________
INSTRUCTIONS TO PROVIDER
TB assessment must be done within three (3) months of the start of class at the beginning of the semester. PLEASE NOTE: TB skin tests, TB
assessment and chest x-rays conducted outside of the United States of America will NOT be accepted under any circumstances. Live vaccines
such as MMR and Varicella must be administered at least 30 days prior to FASET (GT registration) date or vaccine should be received at Georgia
Tech during FASET.

TB Assessment
History Risk:
1. Have you ever had a positive TB skin test?  No  Yes Date of Positive PPD: _____________  
2. Complete current symptom risk assessment. (If present chest x-ray required)
Exposure Risks: If yes to any question, please have the student complete a TB skin test and complete the Tuberculosis Skin Testing Form
1. Have you within the last 2 years, worked or volunteered in the following types of facilities?
Homeless Shelter  No  Yes Long-term Care  No  Yes Hospitals  No  Yes
Rehab Facility  No  Yes Residential Facilities for patients with AIDS  No  Yes
Prisons  No  Yes Nursing Homes  No  Yes

2. Have you recently come into contact with a person who has Tuberculosis?  No  Yes
3. Have you ever been an injection drug user or use of any illicit drugs?  No  Yes
Travel Risks:
Travel of more than 2 weeks to the countries listed below does NOT put a student at high risk. Travel to any other country may put you at high risk.
However, all international students from any country except Canada or the United States must receive a TB assessment in the United States. If at high
risk, then a T-Spot or TB skin test must be placed in the US.
1.  No  Yes
Have you lived or traveled outside of the US for greater than 2 weeks in the last 5 years?
If yes, please list countries lived or visited (MOST RECENT FIRST)
______________________________________________________________________________________________________
Current Symptoms Risk:
Do you currently have any of the following symptoms?
3 weeks or more Persistent Cough  No  Yes Loss of Appetite  No  Yes Persistent Night Sweats  No  Yes
Fever or Chills  No  Yes Unexplained weight loss  No  Yes Hemoptysis  No  Yes

CERTIFICATION OF HEALTHCARE PROVIDER

Is this student HIGH RISK for TB Exposure?  YES (complete TB Skin Testing Form)  No
Name: ___________________________________ Date: ________________Phone # _________________________
Signature: ________________________________
“Low Incidence” areas are defined as areas with reported or estimated incidence of < 20 cases per 100,000 population. Source: World Health
Organization
Andorra Czech Republic Costa Rica Israel Malta Puerto Rico Turks and Caicos
Antigua and Barbuda Denmark Cuba Italy Monaco Saint Kitts and Nevis Islands
Australia Dominica Cyprus Jamaica Montserrat Sweden Vatican City
Austria Finland Germany Jordan Netherlands Switzerland United Arab
Barbados France Greece Libyan Arab Netherlands Antilles St. Lucia Emirates
Belgium Canada Grenada Jamahiriya New Zealand San Marino United Kingdom
Bermuda Cayman Islands Iceland Liechtenstein Norway Slovenia US Virgin Islands
British Virgin Islands Chile Ireland Luxemburg Oman Trinidad and Tobago USA
 GEORGIA INSTITUTE OF TECHNOLOGY

TUBERCULOSIS SKIN TESTING FORM

REQUIRED TO BE COMPLETED FOR HIGH RISK STUDENTS
**RISK DETERMINED BY HEALTHCARE PROVIDER USING TB ASSESSMENT FORM **

PLEASE FAX COMPLETED FORMS TO 404-385-0329. RETAIN A COPY OF THE COMPLETED FORM FOR YOUR RECORDS.

STUDENT INFORMATION
Date: ____________ GTID#:____________ Birth Date:____________ Phone#:_______________
Name (Last, First, Middle) _________________________________________Email:____________________________________
TUBERCULIN SKIN TEST (Only accepted if completed in the United States of America) Live vaccines such as MMR and Varicella must be
administered at least 30 days prior to FASET (GT registration) date or vaccine should be received at Georgia Tech during FASET.

Date placed ____________ L / R Date read___________ (must be within 48 to72 hours)

MMDDYYYY MMDDYYYY
Placed By: __________________________________ Read By: __________________________________
Lot #: ______________ Exp Date: ____________ Result ___________mm (record actual mm of induration, transverse diameter.
MMDDYYYY If no induration, record as “0 mm”)

FINAL INTERPRETATION- Based on Criteria for Tuberculin Positivity below, by Risk Group
 Reaction > 5 mm of Induration
 Human immunodeficiency virus (HIV)-
positive persons
 Patients with organ transplants and other
immunosuppressed patients (receiving the
equivalent of ≥ 15 mg/d of prednisone for 1
month or more
 Fibrous changes on chest x-ray consistent
with prior TB
 Recent contacts of infectious TB case
 POSITIVE  NEGATIVE
 Reaction > 10mm of Induration  Reaction > 15mm of Induration
 Recent immigrants to the U.S. (within the last 5 years)  Person with no risk factors for TB
from high prevalence countries
 Persons with silicosis, diabetes, chronic renal failure,  Persons who are otherwise at low risk and
leukemias and lymphomas, carcinoma of the head, neck are tested at the start of employment, a
and lung, weight loss of ≥10% of ideal body weight, reaction of ≥15 mm is considered positive
gastrectomy, and jejunoileal bypass
 Residents and employees of the high risk congregate
settings.
 Mycobacterial laboratory personnel
 Injecting drug users
 Children less than 5 years of age or infants, children, and
adolescents exposed to adults at high-risk
 Recent conversion (increase of ≥ 10 mm of induration
within the past 2 years

Chest X-RAY (Required if skin test is positive. If history of previous positive skin test, Chest x-ray must be completed in the US.
Chest x-ray must be performed after the date of the positive skin testing)

Date of chest x-ray _____________ Chest x-ray must be completed in US Date of Positive PPD: ________________
MMDDYYYY MMDDYYYY

Result:  NORMAL  ABNORMAL

Treatment for latent TB

Has the student received Anti-Tubercular Drug?  YES  NO

If yes, INH given?  YES  NO Other Treatment:_________________________________________________
Duration of Treatment: From _____________ to ____________
MMDDYYYY MMDDYYYY

CERTIFICATION OF HEALTHCARE PROVIDER

Name: ___________________________________ Date: ________________Phone # _________________________
Signature: ______________________________
Phone: ______________________________
PHYSICAN OFFICE STAMP