International Student TB Screening Form Spring 2025 12-5-2024

Dear International Student,

Welcome to Eastern Illinois University! We are excited that you have selected our institution to further your educational experiences and opportunities. We hope that in the coming semester, you will have a great experience both inside and outside of the classroom.

As you transition to our institution, as a new International Student, you are required to complete Tuberculosis Screening.

THIS FORM IS TO BE COMPLETED BY THE PERSON WHO IS INDICATED AS THE PERSON SUBMITTING THE FORM. HAVING OTHERS ANSWER THESE QUESTIONS AND SUBMITTING THE FORM ONE ANOTHER'S BEHALF IS CONSIDERED FRAUDULENT AND IF DISCOVERED MAY BE REPORTED TO THE DEAN OF STUDENTS FOR DISCIPLINARY/CONDUCT REFERRAL.

We ask that you complete and submit the below form as soon as possible, but no later than Friday, January 24.

Once completed and submitted, we will review the information, and staff from Health and Counseling Services will contact you to provide further direction if needed.
Demographics/Personal Information
Student's First Name *
Student's Last Name/Surname/Family Name *
Date of Birth Date of Birth * / MM / DD YYYY
EIU E# (Include the E) *
Local/US Phone Local/US Phone - ### - ### ####
EIU Email Address *
Secondary/Non-EIU Email Address *
What Country Have You Spent the Majority of the Last 6 Months In *
Tuberculosis (TB) Screening Form
All new International Students must complete this on-line Tuberculosis Screening questionnaire. Once this form is reviewed, you will be contacted by a Health and Counseling Medical Clinic staff member. Some students may need to undergo laboratory testing. If so, laboratory testing will be at the student's expense. If you have completed TB Gold Quantiferin blood testing in the United States in the last 12 months or have been treated for TB in the past, please submit those records to health@eiu.edu.

TB Blood test results conducted outside of the United States, TB Blood test results conducted within the US more than one year ago, and TB skin test results WILL NOT be accepted.
Have you ever been sick/ill and treated for Tuberculosis with antibiotics? *

Have you ever been sick/ill and treated for Tuberculosis with antibiotics? Yes, I have been treated for Active Tuberculosis. Yes, I have been treated for Latent Tuberculosis No, I have never been treated for Tuberculosis I do not know if I have been treated for Tuberculosis
What is your country of birth/childhood? List multiple countries if relevant. *
Please list any countries (besides the US and the country of your birth/childhood) in which you have spent two months or greater in during the last 12 months.
What date did you most recently arrive in, or are planning to arrive in the United States? What date did you most recently arrive in, or are planning to arrive in the United States? * / MM / DD YYYY
Have you ever received the bacille Calmette-Guerin (BCG) tuberculosis vaccine? *

Have you ever received the bacille Calmette-Guerin (BCG) tuberculosis vaccine? Yes No
Have you had any vaccines or injections within the last 28 days/4 weeks? *

Have you had any vaccines or injections within the last 28 days/4 weeks? Yes No
Have you ever had history of a positive TB skin test, a positive TB blood test, or blistering at the site of a TB skin test? *

Have you ever had history of a positive TB skin test, a positive TB blood test, or blistering at the site of a TB skin test? Yes No
Have you ever had chest x-ray showing previous TB infection or disease? *

Have you ever had chest x-ray showing previous TB infection or disease? Yes No
Have you ever taken medication for TB exposure, infection, disease, or a positive TB test? *

Have you ever taken medication for TB exposure, infection, disease, or a positive TB test? Yes No I Do Not Know/Unknown
Do you have a history of inadequately treated TB? *

Do you have a history of inadequately treated TB? Yes No
Have you been exposed to someone with active TB? *

Have you been exposed to someone with active TB? Yes No
Do you have any symptoms of TB disease? Check any that apply. *

Do you have any symptoms of TB disease? Check any that apply. Fatigue Loss of appetite Unexplained weight loss Cough with sputum or mucus or blood Night sweats Chills Chest pain Prolonged cough (more than 3 weeks) Coughing Up Blood Difficulty breathing Weakness I Do Not Have Any of These
Do you currently have any of these risk factors? Check any that apply. *

Do you currently have any of these risk factors? Check any that apply. HIV Infection/AIDS Diabetes Injection/IV of illicit drugs Recent TB infection (within past 2 years) Chest x-ray finding suggestive of previous TB Silicosis Prolonged therapy with steroids Immunosuppressive therapy or other medications, such as medications for cancer Certain types of cancer (e.g., leukemia, Hodgkin’s disease, or cancer of the head and neck) Severe kidney disease Low body weight (10% or more below ideal) General anesthesia within the past 9 months Resided in, volunteered in, or worked in high risk settings such as prisons, homeless shelters, healthcare facilities, etc. I Do Not Have Any of These
Illinois College Immunization Requirement - Not Tuberculosis Requirement
Immunizations

All International Students must submit Immunization Records which meet the Illinois College Immunization Act requirements set by the State of Illinois. These may be uploaded through the below link, e-mailed to immunizations@eiu.edu, or dropped off in person to the Health Education Resource Center located in 2201 Blair Hall.

Information regarding the act, acceptable forms of records, clinics/providers records are not accepted from may be found at: https://www.eiu.edu/health/internationalims.php
Please note your immunization record status: *

Please note your immunization record status: I have already submitted my immunizations via immunizations@eiu.edu I have submitted my immunization records in person to the Health Education Resource Center I will be uploading my immunizations to this form I do not have records to submit at this time, but plan to do so I do not have any immunization records to submit at all
Upload Immunization Records

International students who have copies of immunization records may upload them as electronic files.

YOU MUST UPLOAD THE ENTIRE DOCUMENT, INCLUDING PAGES WHICH HAVE YOUR IDENTIFYING INFORMATION (NAME, ID NUMBERS, BIRTHDATES, ETC.)

Records must be signed and dated by a licensed/registered medical professional, and include a valid professional phone number for the healthcare provider or the provider's organization.

The provider's registration/license number, as well as the healthcare organization's physical address, a professional e-mail address, and a professional phone number should be noted on the organization's stationary/letterhead or the World Health Organization's International Certificate of Vaccination, also referred to as the Carte Jaune or Yellow Card document.

Records are extensively reviewed. Eastern Illinois University reserves the right to refuse to accept records which are unable to be confirmed or validated. A list of clinics and providers not accepted may be found on-line at: https://www.eiu.edu/health/internationalims.php

Records which are believed to be fraudulent or fabricated will not be accepted. Students submitting fraudulent or fabricated immunizations may be referred to the Dean of Students for judicial review and sanctioning. Those found guilty may face consequences including tabled suspension, fines, reprimand, suspension, expulsion, and others.

Attach Files
I certify that I have submitted the above information, that the information is true, and that any and all records are accurate and authentic.

Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

International Student TB Screening Form Spring 2025 12-5-2024

International Student TB Screening Form Spring 2025 12-5-2024

Demographics/Personal Information

Tuberculosis (TB) Screening Form

Illinois College Immunization Requirement - Not Tuberculosis Requirement

Immunizations