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by: Kaleigh O'Reilly

tester Chemistry 1210

Kaleigh O'Reilly

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About this Document

this is a test
General Chem 1
Ted Clark
Class Notes
25 ?




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This 1 page Class Notes was uploaded by Kaleigh O'Reilly on Friday August 12, 2016. The Class Notes belongs to Chemistry 1210 at Ohio State University taught by Ted Clark in Summer 2016. Since its upload, it has received 18 views. For similar materials see General Chem 1 in Chemistry at Ohio State University.


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Date Created: 08/12/16
STUDY ABROAD Health Information Form Congratulations on your acceptance to an Ohio State study abroad program. It is important that we be aware of any past or current medical issues, including mental health conditions, which might affect your participation. This information will be kept confi dential in accordance with applicable law and handled with the highest level of discretion to protect student privacy. Disclosure of such information may be made to appropriate individuals (including program staff and resident directors) and to pwith assistance should the need arise during your study abroad experience. Health tests, certifications, or other actions may also be required prior to departure in certain circumstances. The Office of International Affairs is committed to enabling part icipation in its study abroad programs for all qualified individuals with disabilities. We work closely the Office for Disability Services to provide access. If you have questions about accessibility, need assistance in order to participate, or wish to dis cuss accommodations for a disability, please contact your OIA Study Abroad Coordinator and/or the Office for Disability Services. Accommodations may require extensive planning and communications with foreign contacts, so adequate lead time is critical. Con tact should accordingly be initiated as soon as possible . Completed by Participant Last Name: First Name: M.I.: Birth Date: ___/___/______ Student ID #: Program: Semester(s)/Year(s): Medical History Have you ever been or are you currently being treated for a physical health condition? (If yes, please  Yes explain and list your doctor’s name and contact information for any current physical health condition(s).)  No Have you ever been or are you currently being treated for a mental health condition (psychological or  Yes emotional)? (If yes, please explain and list your doctor’s name and contact information for any current  No mental health condition(s).)  Yes Do you have any allergies? (If yes, please explain.)  No  Yes Are you taking any medications? (If yes, please explain.)  No  Yes Have you had any major injuries, diseases, or ailments in the past five years? (If yes, please explain.)  No  Yes Are you a vegetarian or are you on a restricted diet? (If yes, please explain.)  No Please list any additional information that would be helpful for the program to be aware of during your study abroad experience. I certify that all responses made on this Health Information form are true and accurate to the best of my knowledge. I will promptly notify the Office of International Affairs hereafter of any relevant changes in my health that occur prior to the start of th e program. I understand and acknowledge that fa ilure to disclose any relevant health issues may result in dismissal from the program and/or other action as appropriate. Type Participant Name: ________________________________________ _______ Date: _____________________


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