Entrance Health Forms 2020

Health forms are now available
Please submit health forms by August 15, 2020

Dear Incoming Student,

Welcome to Caltech!

Caltech's Student Wellness Services provides medical care and counseling services to all members of our student community during their time as registered students on campus. In order for us to initiate our support model, we ask that you complete the following required health forms by August 15, 2020. Students with missing or incomplete health forms will have a hold placed on their account by the Office of the Registrar which will prevent registration for classes.

Please note that while an official decision on the fall term and the full resumption of on-campus activities has not yet been made, the Institute and its administrative offices continue to plan for fall term 2020. Information on our current operations and plans is available on Caltech's Coronavirus Information website.

All students on campus for educational activities will be required to follow all Caltech requirements with respect to Entrance Health Forms, immunizations as well as all procedures related to COVID-19 infection prevention, testing, isolation, and quarantine. All students are asked to adhere to the following:

Fill out and submit the Entrance Health Requirements and Forms. These forms are mandatory for all new incoming undergraduate and graduate students who will be on campus at any time during their Caltech academic career. Even if you are uncertain when you will arrive on campus, it is advised you complete the forms now in anticipation that at a future point in time, you will come to the campus.Get the yearly influenza vaccine. In response to the COVID-19 pandemic, students on campus will be required to receive the yearly influenza vaccine when it becomes available in the fall of 2020. Preventing flu is always important, but in the context of the COVID-19 pandemic, it is necessary that everyone in the Caltech community implements all preventative measures possible to reduce illnesses and preserve scarce health care resources.If you are unable to obtain the required immunizations, tests for immunity, or tuberculosis testing at your current location, please make an appointment at Student Wellness Services within one week of your arrival on campus. We can provide these services, but please note that they will be at your expense. Student Wellness Services does not bill insurance and does not submit insurance claims on your behalf. Please upload all required forms by August 15, 2020, even if you require additional testing or immunizations. Student Wellness Services staff will contact you to assist you in completing health form requirements.

Submission Process and Requirements for Health Forms:

By June 15, 2020, you will have access to the Caltech Student Health Portal to submit the following required forms and information. Transmission of all required documents and communication with Student Wellness Services is done through our electronic medical record system on the Caltech Student Health Portal.

You are responsible for reading and responding to any secure messages sent to you from the health services staff. If you have questions about using the Student Health Portal, please see instructions below.

  1. Immunization Form: Please see and follow the instructions below to complete documentation for the required immunizations. Please ask your healthcare provider or your parents if you have difficulty understanding your immunization records.
  2. Tuberculosis Screening: Please see and follow the instructions below to complete documentation for tuberculosis screening.
  3. Insurance Card: Students enrolled in the Caltech UnitedHealthcare Student Resources insurance plan do not need to complete this step. If you are not enrolled in the Caltech UnitedHealthcare Student Resources insurance plan, make a copy of the front and back of your health insurance card and email it to healthforms@caltech.edu.
  4. Health History Questionnaire: Please see and follow the instructions below to complete the required Health History Questionnaire.
  5. Acknowledgments of Privacy Policy and Consent to Treatment: Please see and follow the instructions below to acknowledge the required Privacy Policy and Consent to Treatment agreements.

NCAA Student-Athletes: If you plan to participate in intercollegiate athletics, you will be provided a login by your sports coach to complete additional forms per NCAA bylaws. Follow the instructions sent by your coach to establish your login credentials, then click to access these forms, which are required in order to practice or attend team events. Any questions can be directed to your coach or Mark Becker, Assistant Director for Intercollegiate Operations at 626-395-3262. Before student-athletes accept the rigors of any organized sport, their health must be evaluated by qualified medical personnel. Such an examination should determine whether the student-athlete is medically cleared to engage in a particular sport. The evaluation needs to be conducted by a medical doctor (MD) or doctor of osteopathic medicine (DO) licensed and in good standing in his or her state. The evaluation must be executed within the six-months prior to the start of organized team activity; older exams will not be accepted. Prospective student-athletes must print and complete the "Preparticipation Physical Evaluation," found at gocaltech.com under the Athletic Training page.

Incomplete Forms: Non-compliance or incomplete compliance with these requirements will result in a hold on your account through the Office of the Registrar and the inability to register for classes. The Health Services staff will make three attempts to contact you regarding the completion of these required forms. If you do not complete the forms, you will be referred to the Dean's Office and the Office of the Registrar for further action. Please contact us at 626-395-6393 if you have questions or need assistance.

Deadline: The deadline to complete the above-required forms and information is August 15, 2020.

Contact Us: For any questions or concerns, please contact us. You can send a secure message through the Caltech Student Health Portal or call us at 626-395-6393.

Sincerely,
John Tsai, MD
Student Wellness Services

Health Forms Instructions - A Step-By-Step Guide

Please gather the required documentation to be uploaded:

  1. Immunization records and (if you have them) laboratory test results that show immunity to MMR (measles, mumps, rubella), Chicken Pox (varicella) and Hepatitis B - Please translate your records into English if your records are in another language.
  2. Insurance card - Students enrolled in the Caltech United Health Care Student Resources insurance plan DO NOT need to complete this step. Please make a copy of the front and back of your health insurance card and email it to healthforms@caltech.edu.
  3. Tuberculosis (TB) questionnaire - Follow the instructions to complete the screening form. TB testing, if required, needs to be dated within the last 6 months.

Please upload all files as a PDF or image

Your immunization documentation must meet the following requirements:

  • MMR: Two doses of measles, mumps, and rubella (MMR) or blood test showing immunity (positive titers).
  • Chicken Pox: Two doses of varicella vaccine (chicken pox) or blood test showing immunity (positive titer).
  • Hepatitis B: Three doses of hepatitis B vaccine or blood test showing immunity (positive titer).
  • Tdap: One dose of tetanus, diphtheria, and pertussis (Tdap) given after age 7. Afterwards, booster dose of tetanus and diphtheria (Td) every ten years.
  • Meningitis: One dose of meningococcal conjugate ACWY (meningitis) after age 16 for all students under age 22.

Use this optional immunization worksheet to help organize your immunization data.
Note: PLEASE DO NOT UPLOAD THIS SHEET. You will need to upload your original immunization records and laboratory test results online when prompted.

Please contact IMSS for assistance with your Caltech access credentials.

https://imss.caltech.edu/

Online: Caltech Help
Phone: 626.395.3500
Email: help@caltech.edu


1) Log in and access forms

Video Guide - Accessing Forms

2) Complete the Health History Form

  • Please enter all significant past or current health conditions, surgeries and hospitalizations, current medications, and allergies.

  • Make sure to press "Save Partial" if you are coming back later to finish your forms!
  • Otherwise, hit "Submit Final" if you are done.

  • Accidentally pressed "Submit Final"? Please contact Maria Lopez at mlopez2[at]caltech.edu to reset your form. You will have to redo the entire form again.

Video Guide - Completing the Health History Form

3) Complete the Immunization Record

  • You will need your immunization records and any laboratory tests showing immunity.
  • Enter the dates of vaccines or blood tests showing immunity.
  • Upload your immunization records and any laboratory tests showing immunity at step 12.
    • Please translate your records into English if your immunization records are in another language.

Video Guide - Completing the Immunization Record

3b) Upload the Tuberculosis (TB) Questionnaire

  • Download the Tuberculosis (TB) Questionnaire.
  • Follow the flowchart to complete the form and gather any requested documents. TB testing, if required, needs to be dated within the last 6 months.
  • Upload the completed form and any relevant documents on step 12.

Video Guide - Uploading the Completed Tuberculosis (TB) Questionnaire and Immunization Records

4) Complete the Health Services Treatment Agreement

  • Read through the Health Services Treatment Agreement.
  • Acknowledge and submit your agreement.

Video Guide - Completing the Health Services Treatment Agreement

5) Complete the Notice of Privacy Practices

  • Read through the Notice of Privacy Practices.
  • Acknowledge and submit your agreement.

Video Guide - Completing the Notice of Privacy Practices

6) Submit a copy of your health insurance card

Note: Students enrolled in the Caltech United Health Care Student Resources insurance plan DO NOT need to complete this step.

You're done! Thank you for completing the health entrance requirements! Welcome to Caltech!


Have a question about your health forms? Send us a message on the Student Health Portal.

  • Go to Student Health Portal: https://mycaltechhealth.caltech.edu/
  • Log in using your Caltech access credentials
  • Messages > New Message > I want to send a message about my Health Forms
  • Type in your subject and message and hit Send

Video Guide - Sending a Secure Message

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