Undergraduate Class of 2013

Guide for Completing Required Health Documentation

All entering students are required to meet certain vaccine requirements as well as complete a series of online forms prior to the start of classes. Please carefully review the information below for instructions on how to access and submit all required documentation.

ALL REQUIREMENTS ARE DUE: AUGUST 1, 2009
*Students waiving the Student Insurance plan are NOT exempt from these requirements

Also see below for required forms for Athletes and for students who will be Minors (under the age of 18) as of September 1, 2009.

Vaccine Requirements:

A hard-copy of your immunization records showing proof of all required vaccines must be submitted for authentication (see also ‘Immunization Record' under ‘Online Forms and Check list' section below).

• Tetanus Primary Series
• Tetanus booster -given within the past 10 years
• 2 MMR vaccines - given after 12 months of age and 1 month apart or
  • Two individual vaccine against Measles and Mumps and one individual vaccine for Rubella or
  • Positive immune titers for each disease or
  • Provider documented proof of disease for measles only
• Quadrivalent Meningococcal vaccine - given within the past 5 years
• Tuberculosis Screening Testing (TST) we be determined by completion of online TB Screening Questionnaire (see below)

For a printable list of vaccine requirements click here.

Accessing your Online Health Forms:

Online Health Forms are located through the secure student system Banner. Students should access the Banner system using their personal username and password provided in the information sent from the First Year Office.

The Banner system is accessed through the site: http://www.dartmouth.edu/dplace/

• Enter your Username and password
• Go to your main Banner menu page and click on the link ‘Health Center Online Services' — you may need to temporarily allow pop-ups. Or, to bypass the pop-up blocker, hold down the ‘Ctrl' key while you click on the link.
• If you receive a Security Certificate Notification, please click to continue through to the web page (this will appear on computers with newer security protocols, so not all will receive this message.)
• Proceed to the ‘Forms' link on the left side of the page

**Some Mac computers will not allow access to this page. If you are using a Mac and after following the above instructions are unable to access the page, you may need to try from a different computer.

Online Forms check-list and Instructions:

• Notice of Privacy Practices
• NH Patient's Bill of Rights
• Permission to Treat
• Institutional Affiliate Information System (IAIS) Agreement
• Health History
• Immunization Record
• Tuberculosis Screening Form

Please note: Once submitted, you will not be able to access the form through the website again.

Receipt of our Permission to Treat, Institutional Affiliate Information System (IAIS) Agreement. Notice of Privacy Practices and New Hampshire Patient's Bill of Rights must be acknowledge electronically.

Health History — Please provide general background and family history for our records.

Immunization Record — Please enter your immunization dates into the online form, then send us an authenticated hard-copy of your Immunization Records for verification. If you are missing any required items, please arrange with your Provider to be vaccinated or tested prior to arriving on campus.

Tuberculosis Screening Form — Please answer the questions to determine if an updated Tuberculosis Screening Test (TST) is required. If a TST test is necessary, please print the Testing Form (PDF) at the bottom of the screening page and bring to your Provider for completion.

Athletic History and Physical Form:

The Athletic History and Physical form is required for any undergraduate student who intends to participate, or is considering participation, on a NCAA or Rugby Sport Team.

Minor Form:

The Special Authorization for Minors form is required for any undergraduate student who will be under the age of 18 on or after September 1, 2009.

Frequently Asked Questions:

For your convenience, a link to some of our most frequently asked questions is located here. If you are unable to find the answers you need on this page, you may contact Josey Griggs in the Medical Records Office at 603-646-9403 or e-mail Medical.Records@dartmouth.edu.