International Educator - November/December 2016 - 40

SPECIAL SECTION

Health and Insurance

PA R T T H R E E : H EALTH ASS ESS M ENT FO RM

Healthcare Provider Evaluation
(only required for students who answered "yes" to question #5 on self-assessment checklist: part one.)
All students who answered yes to question #5 on the Self-Assessment Checklist: Part One must meet with a healthcare provider and
submit this completed and signed form at least 6 weeks prior to departure. The student should bring Part One and the appropriate
pages from the CDC Travelers' Health web site (see below) to their doctor's appointment.
STUDENT NAME and E-MAIL ADDRESS: ___________________________________________________________________________

PROGRAM/EXPERIENCE: ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

To the healthcare provider: Thank you for taking the time to meet with this student and complete this form. The student has been
treated for one or more of the conditions or events listed in the Self-Assessment Checklist Part One, Number 5, over the past five years.
Living and studying in an unfamiliar environment can trigger physical and emotional stress and exacerbate current health issues. Familiar
or reliable healthcare or medications might not be readily available to the student in his/her host country.
You are asked to:
n Review

any relevant information provided on the CDC Travelers' Health website for all countries on the student's itinerary.
(See http://wwwnc.cdc.gov/travel/destinations/list.htm).

n Discuss

the student's medical situation with him/her in light of how it may affect the student's international experience.

n Ask

the student about their destination and the demands of the specific program/experience as well as other countries
they might visit that could pose health challenges.

n Advise

the student regarding how potentially dramatic changes in climate, diet, living arrangements, social life, and study demands
may affect him/her abroad.

n Discuss

possible accommodations the student should make or discuss with staff administering or overseeing their overseas program/
experience.

To be completed by healthcare provider:
I have met with the student to discuss his/her medical condition as it relates to his/her intended international experience.
I have encouraged the student to discuss his/her medical condition with one or more of the following: a representative from unit
coordinating his/her program, a representative the disability services office, a health care professional, a representative from the
program provider or host institution, parents, or other family members well in advance of the program's departure date.

NAME OF MEDICAL PROFESSIONAL:

TITLE:

CITY/STATE:

SIGNATURE:

40  

INTERNATIONAL EDUCATOR N O V + D E C .16

DATE:


http://wwwnc.cdc.gov/travel/destinations/list.htm

Table of Contents for the Digital Edition of International Educator - November/December 2016

From the Editor
In Brief
Voices
Act Globally
Tradition and History
Health and Insurance
Education Abroad
International Enrollment
View From Out Here
In Focus
International Educator - November/December 2016 - Cover1
International Educator - November/December 2016 - Cover2
International Educator - November/December 2016 - 1
International Educator - November/December 2016 - From the Editor
International Educator - November/December 2016 - 3
International Educator - November/December 2016 - In Brief
International Educator - November/December 2016 - 5
International Educator - November/December 2016 - 6
International Educator - November/December 2016 - 7
International Educator - November/December 2016 - 8
International Educator - November/December 2016 - 9
International Educator - November/December 2016 - 10
International Educator - November/December 2016 - 11
International Educator - November/December 2016 - Voices
International Educator - November/December 2016 - 13
International Educator - November/December 2016 - 14
International Educator - November/December 2016 - 15
International Educator - November/December 2016 - Act Globally
International Educator - November/December 2016 - 17
International Educator - November/December 2016 - 18
International Educator - November/December 2016 - 19
International Educator - November/December 2016 - 20
International Educator - November/December 2016 - 21
International Educator - November/December 2016 - 22
International Educator - November/December 2016 - 23
International Educator - November/December 2016 - 24
International Educator - November/December 2016 - 25
International Educator - November/December 2016 - Tradition and History
International Educator - November/December 2016 - 27
International Educator - November/December 2016 - 28
International Educator - November/December 2016 - 29
International Educator - November/December 2016 - 30
International Educator - November/December 2016 - 31
International Educator - November/December 2016 - 32
International Educator - November/December 2016 - 33
International Educator - November/December 2016 - 34
International Educator - November/December 2016 - 35
International Educator - November/December 2016 - Health and Insurance
International Educator - November/December 2016 - 37
International Educator - November/December 2016 - 38
International Educator - November/December 2016 - 39
International Educator - November/December 2016 - 40
International Educator - November/December 2016 - 41
International Educator - November/December 2016 - Education Abroad
International Educator - November/December 2016 - 43
International Educator - November/December 2016 - 44
International Educator - November/December 2016 - 45
International Educator - November/December 2016 - 46
International Educator - November/December 2016 - 47
International Educator - November/December 2016 - International Enrollment
International Educator - November/December 2016 - 49
International Educator - November/December 2016 - 50
International Educator - November/December 2016 - 51
International Educator - November/December 2016 - 52
International Educator - November/December 2016 - 53
International Educator - November/December 2016 - View From Out Here
International Educator - November/December 2016 - 55
International Educator - November/December 2016 - In Focus
International Educator - November/December 2016 - Cover3
International Educator - November/December 2016 - Cover4
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