PLUS Student Application Packet 2019-2020

FIU Embrace

Postsecondary Comprehensive Transition Program

Office of Research & Economic Development FIU Embrace 11200 SW 8th Street

MARC 140 Miami, Florida 33199

305-348-5377

The application must be submitted via mail or dropped off in person at the address listed above.

Pake Aplikasyon Etidyan PLUS 2019-2020

FIU Embrace Pwogram Tranzisyon Konplè Apre segondè

Office of Research & Economic Development (Biwo Rechèch ak Devlopman Ekonomik) FIU Embrace 11200 SW 8th Street MARC 140 Miami, Florida 33199 305-348-5377

Ou dwe soumèt aplikasyon an pa lapòs oswa ou depoze l an pèsòn nan adrès ki endike anwo a.

2 Application for Admission This is a postsecondary comprehensive transition program for unique learners who are motivated young adults whose disability is characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills.

In order to be sure that the FIU Embrace at Florida International University is the best match for all applicants, we require an application packet be completed for each student. It is expected that students will demonstrate the following minimal requirements: • The student should have a 3rd grade reading level or demonstrate practical reading skills at the time of the interview • The student must demonstrate basic mathematics understanding and the ability to use a calculator • The student must demonstrate the ability to function independently for a sustained period of time and require minimal supervision • The student must be able to appropriately administer their own prescribed medication, without requiring prompting to do so • The student must not have any history of arrest or severe behavioral and emotional problems • The student must not any have serious persistent mental health and or substance abuse problems • The student must be able to adapt to change and not be overly stressed when things change • The student must have the potential to be successful in competitive employment • The student must express the desire and motivation to complete a postsecondary comprehensive transition program • The student must be between the ages of 18-26 (18-24 at the start of the program) • The student must have exited high school (Proof of HS Diploma/Special Diploma needed). If this student will be exiting high school after the application deadline, then proof of the student already having met the requirements for graduation is required as part of the submitted application. • The student must complete psychological and adaptive testing through FIU Embrace • The student must complete and submit the entire application packet, in order to be considered for the program. No incomplete applications will be accepted.

The applicant must not have any previous record of behavioral, sexual and conduct outburst or previously violated FIU’s student code of conduct.

This is not a certificate program or an accredited college degree program. Students will receive a certificate of completion, NOT a degree from Florida International University.

Note: Not all applicants who submit a completed application and meet the “criteria for admission” will be granted an interview and/or be accepted into the PLUS program; however, all students are welcome to apply. All materials submitted to FIU Embrace will become property of FIU and will not be returned or duplicated for other purposes.

Please contact us via email or phone, if you have any questions regarding the application: [email protected] or [email protected], Phone: (305)348-5377 or ( 305) 348-7938

3 Aplikasyon pou Admisyon Sa se yon pwogram tranzisyon konplè apre segondè pou moun eksepsyonèl k ap aprann, ki se jèn adilt motive ki gen andikap ki karakterize avèk gwo limit alafwa nan fonksyònman entelektyèl ak nan konpòtman pou adaptasyon, ki eksprime dapre konpetans konseptyèl, sosyal, ak adaptasyon pratik.

Pou asire FIU Embrace nan Florida International University se kote ki koresponn pi byen pou tout kandida yo, nou mande pou ranpli yon pake aplikasyon pou chak etidyan. Etidyan yo dwe demontre egzijans minimòm sa yo: • Etidyan an dwe gen yon nivo lekti klas 3yèm ane oswa li demontre konpetans lekti pratik nan moman entèvyou an • Etidyan an dwe demontre konpreyansyon matematik debaz ak kapasite pou itilize yon kalkilatris • Etidyan an dwe demontre kapasite pou fonksyone nan fason endepandan pandan yon peryòd tan pwolonje epi li nesesite yon sipèvizyon minim • Etidyan an dwe kapab pran pwòp medikaman preskripsyon l poukont li, san yo pa oblije ensite l fè sa • Etidyan an pa dwe gen okenn istwa arestasyon ni pwoblèm konpòtmantal ak emosyonèl grav • Etidyan an pa dwe gen okenn pwoblèm sante mantal ak/oswa pwoblèm abi sibstans pèsistan ki grav • Etidyan an dwe anmezi pou adapte l ak chanjman epi li pa dwe gen twòp estrès lè bagay yo chanje • Etidyan an dwe gen potansyèl pou li gen siksè nan travay konpetitif • Etidyan an dwe montre dezi ak motivasyon pou fini yon pwogram tranzisyon konplè apre segondè • Etidyan an dwe gen ant 18-26 lane (18-24 lane nan kòmansman pwogram lan) • Etidyan an dwe te sot nan lekòl segondè (Prèv Diplòm Ayskoul/Diplòm Espesyal obligatwa). Si etidyan sa a ap sot nan lekòl segondè apre dat limit pou aplikasyon an, lè sa li obligatwa pou etidyan an gen prèv li deja ranpli kondisyon pou gradyasyon lè l ap soumèt aplikasyon an. • Etidyan an dwe pase pa FIU Embrace pou fè tès sikolojik ak adaptatif • Etidyan an dwe ranpli ak soumèt pake aplikasyon an annantye, pou yo kapab anvizaje l pou pwogram lan. Yo p ap aksepte aplikasyon ki pa konplè.

Kandida a pa dwe gen okenn ansyen dosye kriz toudenkou nan konpòtman, onivo seksyèl ak nan konduit, oswa li pa dwe te deja vyole kòd konduit etidyan FIU.

Sa pa yon pwogram pou resevwa sètifika ni yon pwogram diplòm kolèj akredite. Etidyan yo ap resevwa yon sètifika finisman, se PA yon diplòm Florida International University.

Remak: Yo p ap akòde yon entèvyou pou tout kandida ki soumèt yon aplikasyon konplè epi ki ranpli “kritè pou admisyon” yo ni/oswa aksepte yo nan pwogram PLUS la; men, yo envite tout etidyan aplike. Tout materyèl yo soumèt nan FIU Embrace ap vin pwopriyete FIU epi yo p ap voye yo tounen ni fè doub pou lòt rezon.

Tanpri sèvi ak mesaj imèl oswa telefòn pou kontakte nou, si w gen nenpòt kesyon konsènan aplikasyon an: [email protected] oswa [email protected], Telefòn: (305)348-5377 oswa (305) 348-7938

4 Application Selection Process A Screening Committee will review applications and select students for admission. Please do not call about the status of your application, as we will not be able to provide information for you over the phone. You will be notified by letter or email regarding the receipt, completion of application documents and whether or not you are granted an interview.

Note: A limited number of applicants will be admitted each year; therefore, a submitted application or interview does not guarantee acceptance into the program.

The decision to offer or deny admission to the program will be made by the Screening Committee in their best judgment and in the best interest of the applicant. Admission will be based on the following criteria: • The applicant must have the authority make his/her own decisions that would allow him/her to fully participate in the program. Therefore, those applicants who have parents/legal guardians (who have retained the legal right to make decisions for the applicant) who have retained plenary guardianship and/or the ability to determine social interactions, are not eligible for the program. • Applicants must be between the ages of 18-24 upon acceptance. • The applicant must have a significant cognitive and/or developmental disability that interferes with their academic performance according to the American Association on Intellectual and Developmental Disabilities (AAIDD) diagnosed by a licensed psychologist or psychiatrist. • The applicant must have sufficient emotional and independent skills to participate in all aspects of the program. • The applicant must be able to sit through 90 minute courses and function independently for at least 3 hour blocks at a time. • The applicant must demonstrate the ability to accept responsibility for his/her actions and maintain respect for him/herself and others and have no history of disruptive or aggressive behaviors. Note: FIU Embrace does not have the personnel necessary to manage/monitor behavioral issues. • The applicant must be able to independently administer his/her own medication, and manage/monitor specialized diets and/or medical illness. Note: There is no personnel available to monitor, manage, or administer medication. The FIU Embrace staff takes no responsibility for specialized diets and/or medical needs. • The applicant must demonstrate the desire to attend the FIU Embrace – PLUS program and adhere to the FIU Student Code of Conduct (https://studentaffairs.fiu.edu/get-support/student- conductand- conflict-resolution/student-code-of-conduct%20/index.php). • The applicant must be able to be fully integrated on the FIU campus. • The applicant must demonstrate the desire to complete all components of the FIU Embrace- PLUS program including assessments/evaluations and surveys needed for consideration to the program. • The applicant must have the potential to successfully achieve his/her goals within the context of the FIU Embrace content and setting. Please complete all sections of this application. It is acceptable for the applicant to receive support, if needed in completing the application. You may attach additional information and pages for writing space if needed. All information is confidential and will not be shared with any outside agencies unless written agreement is provided by those filling out the application. Information will not be returned or duplicated for any purposes.

5 Pwosesis Seleksyon Aplikasyon Yon Komite Seleksyon ap egzamine aplikasyon yo epi l ap chwazi etidyan pou admisyon. Tanpri, pa rele pou w mande nan ki eta aplikasyon w lan ye, paske nou p ap kapab ba w enfòmasyon nan telefòn. N ap fè w konnen nan yon lèt oswa mesaj imèl lè nou resevwa aplikasyon an, èske dokiman aplikasyon yo konplè ak si wi ou non nou akòde w yon entèvyou.

Remak: N ap admèt yon kantite kandida limite chak ane; pakonsekan, si w soumèt yon aplikasyon oswa ou jwenn yon entèvyou, sa pa garanti nou aksepte w nan pwogram lan.

Se Komite Seleksyon an k ap pran desizyon pou ofri oswa refize admisyon nan pwogram lan, dapre meyè jijman pa yo ak nan pi bon enterè kandida a. Admisyon yo ap baze sou kritè sa yo: • Kandida a dwe gen otorite pou pran pwòp desizyon l ki pèmèt li patisipe nan pwogram lan nèt. Pakonsekan, kandida ki gen paran/gadyen legal (ki konsève dwa legal pou pran desizyon pou kandida a) ki konsève lagad legal total e konplè ak/oswa kapasite pou detèmine entèraksyon sosyal, kandida sa yo pa kalifye pou pwogram lan. • Kandida yo dwe gen ant laj 18 ak 24 lane nan moman nou aksepte yo. • Kandida a dwe gen yon gwo andikap koyitif ak/oswa andikap nan devlopman ki jennen rannman akademik li selon Asosyasyon Ameriken pou Andikap Entelektyèl ak Devlòpmantal (American Association on Intellectual and Developmental Disabilities, AAIDD), epi se yon sikològ oswa sikyat lisansye ki dwe fè dyagnostik la. • Kandida a dwe gen ase konpetans emosyonèl ak endepandan pou l patisipe nan tout aspè pwogram lan. • Kandida a dwe kapab chita pandan tout klas 90 minit yo epi fonksyone poukont li pandan omwen 3 blòk èdtan alafwa. • Kandida a dwe demontre kapasite pou aksepte responsablite pou aksyon l poze epi konsève respè pou tèt pa l ak pou lòt moun, epi li pa dwe gen okenn istwa konpòtman tapajè oswa agresif. Remak: FIU Embrace pa gen pèsonèl nesesè pou jere/siveye pwoblèm konpòtman. • Kandida a dwe kapab pran medikaman l poukont li, epi jere/kontwole rejim espesyalize li ak/oswa maladi medikal li. Remak: Pa gen okenn pèsonèl disponib pou siveye, jere, oswa bay medikaman. Pèsonèl FIU Embrace la pa pran okenn responsablite pou rejim espesyalize ak/oswa bezwen medikal. • Kandida a dwe demontre dezi pou swiv pwogram FIU Embrace – PLUS la epi respekte Kòd Konduit Etidyan FIU a (https://studentaffairs.fiu.edu/get-support/student-conductand- • conflict-resolution/student-code-of-conduct%20/index.php). • Kandida a dwe kapab entegre l nèt nan kanpis FIU a. • Kandida a dwe demontre dezi pou fè tout eleman ki nan pwogram FIU Embrace- PLUS la, ansanm ak kontwòl/evalyasyon ak ankèt ki nesesè pou konsiderasyon pou pwogram lan. • Kandida a dwe gen posiblite pou reyalize objektif li avèk siksè nan kontèks kontni ak anbyans FIU Embrace la. Tanpri ranpli tout seksyon yo nan aplikasyon sa a. Li akseptab pou kandida a resevwa sipò pou l ranpli aplikasyon an, si sa nesesè. Ou ka mete enfòmasyon ak paj anplis pou jwenn espas pou ekri si sa nesesè. Tout enfòmasyon yo konfidansyèl epi nou p ap pataje yo avèk okenn ajans deyò sof si moun ki ranpli aplikasyon an bay yon akò alekri. Nou p ap voye enfòmasyon yo tounen ni fè doub yo pou okenn rezon.

6 Application Checklist

Applicant Name:

Once your completed application has been submitted, you will be notified of receipt of the completed application by letter or email. NOTE: Applications will not be considered until ALL requested information is received.

Recommendation must be included in a sealed envelope with signature across the seal.

Please drop off/mail application materials to: FIU Embrace 11200 SW 8th Street MARC 140 Attn: Kimberly Rivera Miami, Florida 33199

Application Checklist:

1.  Student and Family Information/Emergency Contact Information Form 2.  Employment History Form 3.  Special Accommodations Form 4.  Medical History/Medical Insurance Form 5.  Immunization Documentation Form 6.  Physical Examination Form 7.  Personal Support Inventory – Family/Guardian Completed 8.  Student Questionnaire – Student Completed (indicate if scribe is used) 9.  3 Letters of Recommendation - with completed inventories 10.  Copy of High School/Special Diploma or Proof that the student currently meets criteria for graduation from High School

Letters of Recommendation should be submitted by three persons who have known the applicant for at least one year. The recommendations should represent each of the following areas:

1. Education 2. Vocational/Employment 3. Community Involvement

Letters must be submitted using the Recommendation Forms included in this packet and must be returned with the application packet in sealed envelopes as directed on the form.

7 Lis Verifikasyon Aplikasyon

Non Kandida a:

Depi ou fin soumèt aplikasyon ou ranpli a, n ap voye yon lèt oswa mesaj imèl pou fè w konnen nou resevwa aplikasyon ou ranpli a. REMAK: Nou p ap travay sou aplikasyon yo jiskaske nou resevwa TOUT enfòmasyon obligatwa yo.

Rekòmandasyon yo dwe nan yon anvlòp kachte ki gen siyati atravè kote anvlòp la kachte a.

Tanpri depoze/poste dokiman aplikasyon yo nan: FIU Embrace 11200 SW 8th Street MARC 140 Attn: Kimberly Rivera Miami, Florida 33199

Lis Verifikasyon Aplikasyon:

1.  Fòm Enfòmasyon Etidyan ak Fanmi/Enfòmasyon pou Kontak pou Ijans 2.  Fòm pou Istwa Travay 3.  Fòm pou Aranjman Espesyal 4.  Fòm pou Istwa Medikal/Asirans Medikal 5.  Fòm Dokiman Vaksinasyon 6.  Fòm pou Egzamen Fizik 7.  Envantè Sipò Pèsonèl – Fanmi/Gadyen an Ranpli 8.  Kesyonè Etidyan - Etidyan an Ranpli (endike si li itilize yon moun pou ekri) 9.  3 Lèt Rekòmandasyon - avèk envantè ranpli yo 10.  Kopi Diplòm Lekòl Segondè/Espesyal oswa Prèv etidyan an satisfè aktyèlman kritè pou diplome nan Lekòl Segondè

Se twa moun ki konnen kandida a pandan yon ane omwen ki dwe soumèt lèt rekòmandasyon yo. Rekòmandasyon yo dwe reprezante chak nan domèn sa yo:

1. Edikasyon 2. Pwofesyonèl/Travay 3. Patisipasyon Kominotè

Yo dwe sèvi ak avèk Fòm pou Rekòmandasyon ki enkli nan pake sa a pou soumèt lèt yo epi yo dwe voye yo tounen avèk pake aplikasyon an nan anvlòp kachte jan yo endike sou fòm lan.

Student Information/Background

To be filled out by: Parent/Family/Guardian

Enfòmasyon/Bakgrawonn Etidyan an

Moun ki dwe ranpli pati sa a se: Paran/Fanmi/Gadyen

10 Referral Source:/ Sous Referans:

Please indicate how you heard about the FIU Embrace PLUS program:/ Tanpri endike kijan ou te fè tande pale de pwogram FIU Embrace PLUS la:  Current/former FIU Embrace LIFE/PLUS student/ Antyèl/ansyen etidyan FIU Embrace LIFE/PLUS

 FIU Embrace email blast/ Mesaj imèl FIU Embrace voye bay yon pakèt moun

 FIU Embrace Outreach Event/ Evènman Sansibilizasyon FIU Embrace

 FIU Embrace website/ Sitwèb FIU Embrace

 Florida Consortium for Inclusive Higher Education (FCIHE) Partner (please specify):/ Patnè Konsòsyòm pou Ansèyman Siperyè Enklizif nan Florid (Florida Consortium for Inclusive Higher Education, FCIHE) (tanpri bay presizyon): ______

 Other FIU Department (please specify):/ Lòt Depatman FIU (tanpri bay presizyon):______

 Miami-Dade/Broward County Public Schools (MDCPS) Special Education Division (SPED)/ Divizyon Edikasyon Espesyal (Special Education Division, SPED) Lekòl Piblik Konte Miami-Dade/Broward (Miami-Dade/Broward County Public Schools, MDCPS)

 Special Olympics of Miami-Dade/ Je Olenpik Espesyal nan Miami-Dade

 Vocational Rehabilitation / Reyadaptasyon Pwofesyonèl

 Other (please specify):/ Lòt (tanpri bay presizyon):______

11 Student Information/ Enfòmasyon Etidyan an

Last Name/ Non Fanmi First Name/ Prenon Middle Name/ Dezyèm Prenon

Home Phone/ Telefòn Kay Student Cell Phone/ Telefòn Selilè Etidyan an

Address/ Adrès

City/ Vil State/ Eta Zip Code/ Kòd Postal

Birth Date/ Dat Nesans Social Security Number*/ Nimewo Sekirite Sosyal*

Email Address/ Adrès Imèl Disability/ Andikap

*Your SSN is confidential and under federal law it is protected and will not be disclosed to unauthorized parties. Disclosures may be authorized for the purpose of available financial aid, academic transcripts or accountability research./ *Nimewo Sekirite Sosyal (SSN) ou konfidansyèl epi li pwoteje anba lwa federal, epi yo p ap divilge l bay lòt pati ki pa gen otorizasyon. Ka gen otorizasyon pou divilgasyon pou èd finansye ki disponib, relve nòt akademik oswa rechèch responsabilite.

Student receives support or services from (please check those that apply):/ Etidyan an resevwa sipò oswa sèvis nan (tanpri tcheke sa yo ki aplike):

 Supplemental Security Income/ Revni Sekirite Siplemantè

 Division of Development Disabilities/ Divizyon Andikap nan Devlopman

 Medical Assistance/ Asistans Medikal

 Social Security Disability/ Andikap Sekirite Sosyal

 Vocational Rehabilitation/ Reyadaptasyon Pwofesyonèl Vocational Rehabilitation Counselor name:/ Non Konseye Reyadaptasyon Pwofesyonèl la: Vocational Rehabilitation Counselor email:/ Imèl Konseye Reyadaptasyon Pwofesyonèl la: Vocational Rehabilitation Counselor phone number:/ Nimewo Telefòn Konseye Reyadaptasyon Pwofesyonèl la

 Educational Services (IDEA Funding)/ Sèvis Edikasyon (Finansman IDEA)

 Other (please describe):/ Lòt (tanpri bay deskripsyon):

12 Family Information/ Enfòmasyon sou Fanmi

Student lives with:/ Etidyan an ap viv avèk:

Both Parents Mother Father Guardian(s) Other/ Toude Paran yo Manman Papa Gadyen (yo) Lòt

Is student his/her own guardian?/ Èske etidyan an se pwòp gadyen tèt li?

Yes/ Wi No/ Non

If no, please indicate the type of guardianship that is in place:/ Si se non, tanpri endike ki kalite lagad legal ki anplas:______

Last Name/ Non Fanmi First Name/ Prenon MI/ Inisyal Dezyèm prenon

Home Phone/ Telefòn Kay Cell Phone/ Telefòn Selilè

Address/ Adrès

City/ Vil State/ Eta Zip Code/ Kòd Postal

Occupation/Employer/ Okipasyon/Anplwayè Work Phone/ Telefòn Travay

Email Address/ Adrès Imèl

13 Father/Guardian/ Papa/Gadyen

Last Name/ Non Fanmi First Name/ Prenon MI/ Inisyal Dezyèm prenon

Home Phone/ Telefòn Kay Cell Phone/ Telefòn Selilè

Address/ Adrès

City/ Vil State/ Eta Zip Code/ Kòd Postal

Occupation/Employer/ Okipasyon/Anplwayè Work Phone/ Telefòn Travay

Email Address/ Adrès Imèl

14 Siblings/ Frè/Sè

Name/ Non Age/ Laj

Emergency Contact Information/ Enfòmasyon pou Kontak pou Ijans

Name / Non Phone Number/ Nimewo Telefòn

Relationship to applicant/ Relasyon avèk kandida a

Name / Non Phone Number/ Nimewo Telefòn

Relationship to applicant/ Relasyon avèk kandida a

15 Employment History/ Istwa Travay Paid Work Experience/ Eksperyans Travay ak Salè Employer/Contact Info./ Job Responsibilities/ Dates at this Job/ Reason for Leaving/ Anplwayè/Enfòmasyon Responsablite Travay Dat yo nan Djòb Rezon ki fè li Kite Kontak. sa a

Volunteer Work Experience/ Eksperyans Travay Volontè Employer/Contact Info./ Job Responsibilities/ Dates at this Job/ Reason for Leaving/ Anplwayè/Enfòmasyon Responsablite Travay Dat yo nan Djòb Rezon ki fè li Kite Kontak. sa a

16 What work experiences do you have an interest in or enjoy?/ Ki eksperyans travay ki enterese w oswa ke w renmen?

17 Special Accommodations/ Aranjman Espesyal

Do you have any limitations or support needs that require any special accommodations/ADA accessibility in order to fully participate in the program?/ Èske w gen nenpòt limit oswa bezwen sipò ki mande nenpòt aranjman espesyal/aksesiblite ADA pou w patisipe nèt nan pwogram lan?

 Yes/ Wi  No / Non

If yes, please describe:/ Si se Wi, tanpri bay deskripsyon:

Do you have any limitations, support needs, or other issues related to public transportation?/ Èske w gen nenpòt limit, bezwen sipò, oswa lòt pwoblèm ki gen rapò ak transpò piblik?

 Yes/ Wi  No/ Non

If yes, please describe:/ Si se Wi, tanpri bay deskripsyon:

18 Medical History/ Istwa Medikal

Please give a brief description of your medical history, including any disability diagnoses that you may have:/ Tanpri, bay yon deskripsyon tou kout sou istwa medikal ou, ansanm ak nenpòt dyagnostik andikap ou ka genyen:

Please list any significant medical or physical conditions, including severe allergies, which may affect your participation in classroom, social, or recreational activities on campus:/Tanpri endike tout gwo pwoblèm medikal oswa fizik, ankontan alèji grav, ki ka afekte patisipasyon w nan salklas, aktivite sosyal oswa aktivite lwazi nan kanpis la

Note: If the applicant must take medications while at FIU he/she must be independent in administering his/her medications. Florida International University and FIU Embrace do not have the personnel nor facilities to administer medications. This capability is not included in any of the FIU Embrace program or college services./ Remak: Si kandida a dwe pran medikaman pandan li nan FIU, li dwe kpab pran medikaman li poukont li. Florida International University ak FIU 19 Embrace pa gen pèsonèl ni enstalasyon pou bay medikaman. Kapasite sa a pa enkli nan okenn pwogram FIU Embrace oswa sèvis kolèj.

Are you independent in self-care such as toileting, basic hygiene including toothbrushing, and showering?/ Èske w endepandan pou pram swen tèt ou tankou ale nan twalèt, ijyèn debaz ki gen ladan bwose dan, ak pran douch?

 Yes/ Wi  No/ Non

20 Medical Insurance Information/ Enfòmasyon sou Asirans Medikal

Name of Insurance Company:/ Non Konpayi Asirans lan: Primary Subscriber Name:/ Non Abòne Prensipal la: Policy Number:/Nimewo Kontra Asirans lan:

In the space below, please provide any other medical information that you feel would be important regarding your participation in this program. Also, please attach a copy (front and back) or your insurance card./ Nan espas ki anba a, tanpri bay nenpòt lòt enfòmasyon medikal ou santi ki ta enpòtan pou patisipasyon w nan pwogram sa a. Epitou, tanpri mete yon kopi (devan ak dèyè) oswa kat asirans ou an.

STUDENT HEALTH SERVICES *IMPORTANT* PLEASE FOLLOWTHESE INSTRUCTIONS TO COMPLYWITH FLORIDA INTERNATIONALUNIVERSITY’S IMMUNIZATIONPOLICY

The FIU Immunization Documentation Form must be processed prior to registering for your classes. The last page of this document (and requested lab reports) is the only Immunization Documentation Form that will be accepted. Please email, fax, or mail ONLY the completed FIU Immunization Documentation Form provided on the last page of this document (and lab reports as needed). Note: Military service records are the only exception to this policy. A military service record which includes health information that meets, or exceeds, FIU’s immunization policy requirements is an acceptable form of documentation. Any other forms of documentationwill be disregarded and shredded.

Have a doctor’s office, clinic, or health department fill out the FIU Immunization Documentation Form. An official stamp and official signature from one of these entities must be included for this document to be complete and approved.

Include the student’s Panther ID on all correspondence. Print all student information legibly.

For minors (students under 18): A parent/guardian signature must be included for immunization waivers.

KEEP A COPY FOR YOUR RECORDS. This ensures that you can easily refer to what was sent to us in the event that we are unable to process your documentation for any reason. DO NOT WAIT

Please email, fax, or mail only the completed FIU Immunization Documentation Form FOUR WEEKS PRIOR TO DESIRED REGISTRATION DATE to:

[email protected]

Florida International University, Student Health Services:

Modesto Maidique Campus Biscayne Bay Campus SHS - 132 OR 11200 S.W. 8 Street Miami, FL 33199 WUC – 307 305-348-3336 (FAX) 3000 N.E. 151 Street North 305-348-2688 Miami, FL 33181

For more information, visit the FIU Student Health Services web page on immunizations at: studenthealth.fiu.edu/immunization.

FEV-09.27.16-p.1

SÈVIS SANTE ETIDYAN *ENPÒTAN* TANPRI, SWIV ESPLIKASYON SA YO POU W KONFÒME W AVÈK RÈGLEMAN FLORIDA INTERNATIONAL UNIVERSITY POU VAKSINASYON

Yo dwe travay sou Fòm Dokiman Vaksinasyon FIU a anvan w enskri pou klas ou yo. Sèl Fòm Dokiman Vaksinasyon n ap aksepte se dènye paj dokiman sa a (ak rapò laboratwa yo mande yo). Tanpri voye SÈLMAN pa imèl, faks, oswa pa lapòs Fòm Dokiman Vaksinasyon FIU yo bay sou dènye paj dokiman sa a (ak rapò laboratwa yo si sa nesesè). Remak: Sèl eksepsyon pou règleman sa a se dosye sèvis militè. Yon dosye sèvis militè ki gen ladan enfòmasyon medikal ki respekte, oswa ki depase egzijans règleman vaksinasyon FIU yo se yon fòm dokiman ki akseptab. N ap inyore ak chire nenpòt lòt fòm dokiman.

Fè yon kabinè doktè, klinik oswa depatman sante ranpli Fòm Dokiman Vaksinasyon FIU a. Dwe gen yon so ofisyèl ak siyati ofisyèl youn nan antite sa yo pou dokiman sa a konplè ak apwouve.

Mete ID Panther etidyan an sou tout korespondans yo. Ekri tout enfòmasyon etidyan an byen lizib.

Pou minè (etidyan ki poko gen 18 an): Dwe gen yon siyati paran/gadyen pou renonsyasyon vaksinasyon.

KENBE YON KOPI POU ACHIV OU. Sa ap asire ou kapab tcheke fasilman sa ou te voye ban nou sizoka nou pa kapab travay sou dokiman ou yo pou yon rezon kèlkonk. PA RETE TANN

Tanpri voye pa imèl, pa faks, oswa pa lapòs Fòm Dokiman Vaksinasyon FIU ou fin ranpli a sèlman KAT SEMÈN AVAN DAT ENSKRIPSYON OU VLE A nan:

[email protected]

OSWA

Florida International University, Student Health Services:

Modesto Maidique Campus Biscayne Bay Campus SHS - 132 OSWA 11200 S.W. 8 Street Miami, FL 33199 WUC – 307 305-348-3336 (FAKS) 3000 N.E. 151 Street North 305-348-2688 Miami, FL 33181

Pou jwenn plis enfòmasyon, vizite paj wèb Sèvis Sante Etidyan FIU sou Vaksinasyon nan: studenthealth.fiu.edu/immunization.

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STUDENT HEALTH SERVICES IMMUNIZATION POLICY As a prerequisite to registration, Florida International University requires all students to comply with the following immunization policy regulations from the Florida Board of Governors regarding measles, mumps, rubella, hepatitis B and meningococcal meningitis immunity: 1. Measles, Mumps, Rubella: • All students born on or after January 1, 1957 must present documented proof of immunity to measles (rubeola) and German measles (Rubella), as described below: Acceptable Proof of Immunity consists of: a. Proof of two (2) vaccinations (doses) of MMR (Measles/Mumps/Rubella) received at least 28 days apart b. Proof of two doses of measles and one dose of rubella • Vaccinations must have been received on or after your first birthday • Vaccinations must have been received in 1969 or later c. Proof of immunity by way of a blood test lab result (measles and rubella titer)

Meningitis and Hepatitis B • All students must present documented proof of vaccination/immunity to meningococcal meningitis and hepatitis B as described below: Acceptable Proof of Immunity consists of:

c. A written statement from a healthcare provider documenting a diagnosis of hepatitis B. Must include date of diagnosis, be signed by the healthcare provider and be on his/her official stationery. This is acceptable for hepatitis B only and does not apply to meningococcal meningitis.

Temporary Deferments: Temporary deferments are acceptable for the following conditions: a. Documented pregnancy or fertility treatment b. Documentation of breastfeeding c. Documented illness Deferment status requests must be submitted to the Student Health Services at least four weeks prior to registration and the request must be signed by a healthcare provider and be on his/her official stationery.

Exemptions: You will be exempt from the pre-registration immunization requirement for measles, mumps, and rubella, only if youmeet any one of the following three criteria: a. You were born before January 1, 1957. b. Medical Exemption: To claim a medical exemption, you must produce a letter from a healthcare provider, signed on his/her stationery, stating the medical reason(s) why you are not able to receive the measles and/or rubella vaccine(s) and for how long – a permanent or temporary medical condition warranting exemption. c. Religious Exemption: For details on how to claim religious exemption, please visit our website at studenthealth.fiu.edu. We strongly recommend all students vaccinate themselves against these diseases. Students declining to receive vaccination for Meningitis and/or HepatitisB must accept a waiver of liability acknowledging that they have read the provided information pertaining to the disease(s), and despite knowledge of the risks have decided to waive receiving the vaccine. These waivers can be viewed and accepted on my.fiu.edu under the “StudentHealth Portal” tab by selecting the “ImmunizationWaivers” link.

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SÈVIS SANTE ETIDYAN RÈGLEMAN SOU VAKSINASYON Kòm yon kondisyon avan enskripsyon, Florida International University mande pou tout etidyan konfòme yo avèk règleman politik vaksinasyon annapre la yo ki soti nan Konsèy Gouvènè Florid konsènan iminite pou lawoujòl, malmouton, ribeyòl, epatit B ak menenjit menengokoksik: 1. Lawoujòl, Malmouton, Ribeyòl: • Tout etidyan ki fèt nan dat 1ye janvye 1957 oswa apre dat sa dwe prezante dokiman prèv iminite kont lawoujòl (rubeola) ak lawoujòl Alman (Rubella), jan li dekri anba a: Prèv Iminite Akseptab gen ladan: d. Prèv de (2) (dòz) vaksen MMR (Measles/Mumps/Rubella) li te resevwa ak 28 jou entèval omwen e. Prèv de (2) dòz lawoujòl ak yon dòz ribeyòl • Ou dwe te resevwa vaksen yo nan premye anivèsè nesans ou oswa apre • Ou dwe te resevwa vaksen yo an 1969 oswa apre f. Prèv iminite pa mwayen yon rezilta tès san (tès kantite antikò kont lawoujòl ak ribeyòl)

Menenjit ak Epatit B • Tout etidyan yo dwe prezante dokiman prèv sou vaksinasyon/iminite pou menenjit menengokoksik ak epatit B jan li dekri anba a: Prèv Iminite Akseptab gen ladan:

c. Yon deklarasyon alekri nan men yon founisè swen sante ki dokimante yon dyagnostik epatit B. Dwe gen ladan dat dyagnostik la, founisè swen sante a dwe siyen, epi deklarasyon an dwe sou papye ofisyèl li. Sa akseptab pou epatit B sèlman, epi li pa aplike pou menenjit menengokoksik.

Ajounman Tanporè: Ajounman tanporè yo akseptab pou kondisyon sa yo: d. Gwosès oswa tretman pou fètilite ki pwouve ak dokiman e. Dokiman prèv alètman matènèl f. Maladi ki pwouve ak dokiman Ou dwe soumèt demann kondisyon ajounman yo bay Sèvis Sante Etidyan kat (4) semèn omwen anvan enskripsyon, epi yon founisè swen sante dwe siyen l, epi li dwe sou papye ofisyèl founisè a.

Egzanpsyon: W ap egzante pou egzijans vaksinasyon anvan enskripsyon pou lawoujòl, malmouton, ak ribeyòl, sèlman si w ranpli nenpòt nan twa kritè sa yo: d. Ou te fèt anvan 1ye janvye 1957. e. Ekzanpsyon Medikal: Pou w reklame yon egzanpsyon medikal, ou dwe bay yon lèt founisè swen sante, ki siyen, si sou papye ofisyèl li, ki deklare rezon medikal la (yo) ki fè ou pa kapab pran vaksen kont lawoujòl ak/oswa ribeyòl (yo) ak pou konbyen tan – yon pwoblèm medikal pèmanan oswa tanporè jistifye yon ekzanpsyon. f. Ekzanpsyon Relijye: Pou detay sou fason pou reklame yon egzanpsyon relijye, tanpri vizite sitwèb nou an nan studenthealth.fiu.edu. Nou rekòmande atoutfòs pou tout etidyan vaksinen tèt yo kont maladi sa yo. Etidyan ki refize resevwa vaksen pou Menenjit ak/oswa Epatit B dwe aksepte yon renonsyasyon responsablite pou yo rekonèt yo te li enfòmasyon yo bay konsènan maladi a (yo), epi malgre yo konnen risk yo, yo te deside pou yo pa resevwa vaksen an. Ou ka wè ak aksepte renonsyasyon sa yo nan my.fiu.edu nan seksyon “Student Health Portal” ; pou fè sa, chwazi lyen “Immunization Waivers” .

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STUDENT HEALTH SERVICES

HEPATITIS B INFORMATION Hepatitis B is a serious infectious disease caused by a virus that attacks the liver. The hepatitis B virus (HBV) can cause life-long infection that may lead to cirrhosis (scarring) of the liver, liver cancer, liver failure, or death. There is no cure for hepatitis B, but the infection can be prevented by vaccination. Students wishing to decline this vaccine must read the information provided below. Signing a waiver indicates that you understand the possible risk involved in not receiving this immunization.

Hepatitis B Vaccine You are encouraged to receive this series. Students in many Academic Health Programs are required to have the HBV series. Students wishing to decline this vaccine must read the information provided below. Signing a waiver indicates that you unders tand the possible risk involved in not receiving this immunization. If you are under the age of 18, a parent or guardian must sign the waiver for you. The vaccine is usually administered as a three-dose series on a 0-, 1-, and 6-month schedule. The 2nd dose must be given at least 28 days after the first dose; the third dose must be given at least 56 days after the second dose and at least 112 days after the first dose.

Symptoms of the Disease Symptoms of hepatitis B can resemble the flu and may include fever, loss of appetite, low energy, joint pain, cramping, or nausea and vomiting, as well as jaundice (yellow skin or eyes). However, in about 50 percent of cases, hepatitis B causes no symptoms and some of these become chronic carriers who are able to transmit the disease to others.

Transmission of the Disease Hepatitis B is contagious and spreads when the blood or other body fluids of a person with the virus are absorbed into an individual’s blood stream. The hepatitis B virus can live in all body fluids of an infected person, including blood, saliva, semen, and vaginal fluids. It can enter the body through cuts, tears, or abrasions in the skin and through mucous membranes of the mouth, vagina, anus, and eyes. Hepatitis B can be transmitted through sexual contact; by sharing razors, toothbrushes, shared needles for drug injection, or by getting a tattoo or body piercing using non-sterile instruments or needles.

Risk Factors forHepatitis B Anyone who comes in contact with the blood or body fluids of an infected person is at risk for hepatitis B. Certain behaviors can increase the risk, including unprotected sex (vaginal, anal, and oral); contact sports (sports during which players may be exposed to each other’s blood or saliva); getting a tattoo or body piercing; sharing items such as razors, earrings, and toothbrushes; sharing injection drug paraphernalia; travel abroad to areas where the disease is widespread; health care and other occupations that involve exposure to infected blood or body fluids; and household contact with someone with chronic infection.

Vaccination Recommendations for College Students A vaccine is available to help protect against hepatitis B. The U.S. Centers for Disease Control and Prevention (CDC) recommends vaccination of everyone age 18 and under, and anyone at high risk for hepatitis B. The American College Health Association (ACHA) recommends that all college students be vaccinated and the National Collegiate Athletic Association (NCAA) recommends that all student athletes be vaccinated. The hepatitis B vaccine is safe and effective. You cannot get the disease from the vaccine. The most common side effect of the vaccine is soreness at the site of the injection.Vaccination requires a series of three shots over a six-month period. After that, a booster shot is usually not necessary. The vaccine is effective in protecting over 96 percent of those who complete the three-dose vaccination series.

Other Forms of Prevention In addition to vaccination, people can modify their behavior by using condoms during sex and avoiding tattooing and body piercing with non-sterile instruments or techniques. One also can avoid sharing needles, razors, or toothbrushes. For more information about Hepatitis B and other infectious diseases:

To learn more about hepatitis B and other infectious diseases, as well as available vaccines, please contact your physician or visit the CDC web site at www.cdc.gov and/or the FIU Student Health Services web site at: studenthealth.fiu.edu.

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SÈVIS SANTE ETIDYAN

ENFÒMASYON SOU EPATIT B Epatit B se yon maladi atrapan akòz yon viris ki atake fwa a. Viris Epatit B (HBV) a ka lakòz enfeksyon ki avi ki ka abouti nan siwoz (sikatris) nan fwa a, kansè nan fwa, defayans fwa a, oswa lanmò. Pa gen gerizon pou epatit B, men ou ka anpeche enfeksyon an ak vaksinasyon. Etidyan ki vle refize vaksen sa a dwe li enfòmasyon ki endike anba a. Lè w siyen yon renonsyasyon, sa endike ou konprann posiblite risk ki gen si w pa resevwa vaksen sa a.

Vaksen kont Epatit B Nou ankouraje pou w pran seri sa a. Etidyan nan anpil Pwogram Sante nan Inivèsite oblije pran seri HBV a. Etidyan ki vle refize vaksen sa a dwe li enfòmasyon ki endike anba a. Lè w siyen yon renonsyasyon, sa endike ou konprann posiblite risk ki genyen si w pa resevwa vaksen sa a. Si w poko gen laj 18 lane, yon paran oswa gadyen dwe siyen renonsyasyon an pou ou. Anjeneral yo bay vaksen an sou fòm yon seri twa-dòz nan yon kalandriye 0, 1-, ak 6-mwa. Yo dwe bay 2yèm dòz la 28 jou omwen apre premye dòz la; yo dwe bay twazyèm dòz la 56 jou omwen apre dezyèm dòz la ak 112 jou omwen apre premye dòz la.

Sentòm Maladi a Sentòm epatit B ka sanble ak grip epi yo ka gen ladann lafyèv, pèt apeti, mank enèji, doulè nan jwenti, kranp, oswa kèplen ak vomisman, ansanm ak lajonis (po oswa je jòn). Men, nan 50 pousan ka apeprè, epatit B a pa bay okenn sentòm, epi kèk nan ka sa yo vin pòtè kwonik ki kapab transmèt maladi a bay lòt moun.

Transmisyon Maladi a Epatit B atrapan epi li transmèt lè san oswa lòt likid kò yon moun ki gen viris la absòbe nan sikilasyon san yon lòt moun. Viris epatit B a ka viv nan tout likid kò yon moun ki enfekte, tankou san, saliv, espèm, ak likid nan vajen. Li ka antre nan kò a nan fann sou po, dechiri, oswa grafouyen nan po, ak atravè membràn bouch, vajen, twou dèyè (anis), ak zye. Epatit B ka transmèt nan kontak seksyèl; nan pataje razwa, bwòsadan, nan pataje zegwi pou pran piki dwòg, oswa nan fè tatou oswa pèse kò avèk enstriman oswa zegwi ki pa esteril.

Faktè Risk pou Epatit B Nenpòt ki moun ki vin an kontak ak san oswa likid kò yon moun ki enfekte, riske pran epatit B. Sèten konpòtman ka ogmante risk la, ki gen ladan sèks san pwoteksyon (nan vajen, nan twou dèyè, ak nan bouch); espò kontak (espò kote jwè yo ka ekspoze nan san oswa saliv youn lòt); nan fè tatou oswa pèse kò ; nan pataje atik tankou razwa, zanno, ak bwòsadan; nan pataje ekipman pou pran piki dwòg; nan vwayaj aletranje nan zòn kote maladi a gaye anpil; travay swen sante ak lòt okipasyon ki gen ladann ekspozisyon nan san oswa likid kò ki enfekte; ak nenpòt kontak nan kay avèk yon moun ki gen enfeksyon kwonik.

Rekòmandasyon pou Vaksinasyon pou Etidyan Kolèj Gen yon vaksen ki disponib pou ede pwoteje kont epatit B. Sant pou Kontwòl ak Prevansyon Maladi (CDC) Ozetazini rekòmande vaksinasyon pou tout moun ki gen laj 18 lane ak pi piti, ak pou nenpòt moun ki gen gwo risk pou trape epatit B. Asosyasyon Ameriken pou Sante nan Kolèj (American College Health Association, ACHA) rekòmande pou tout etidyan kolèj pran vaksen epi Asosiyasyon Nasyonal Espò nan Kolèj (National Collegiate Athletic Association, NCAA) rekòmande pou tout etidyan atlèt yo pran vaksen an. Vaksen kont epatit B a san danje epi li efikas. Ou pa ka pran maladi a nan vaksen an. Efè segondè ki pi kouran ak vaksen an se doulè nan kote w pran piki a. Vaksinasyon an mande yon seri ki gen twa vaksen pandan yon peryòd sis mwa. Apre sa, yon vaksen rapèl pa nesesè anjeneral. Vaksen an pwoteje avèk efikasite plis pase 96 pousan moun ki fin pran seri vaksinasyon twa-dòz la.

Lòt Fòm Prevansyon Anplis vaksinasyon, moun ka modifye konpòtman yo avèk itilizasyon kapòt pandan y ap fè sèks, ak nan evite fè tatou ak pèse kò yo avèk enstriman oswa teknik ki pa esteril. Epitou, yon moun ka evite pataje zegwi, razwa, oswa bwòsadan. Pou jwenn plis enfòmasyon sou epatit B ak lòt maladi atrapan:

Pou jwenn plis enfòmasyon sou epatit B ak lòt maladi atrapan, ansanm ak sou vaksen ki disponib yo, tanpri kontakte doktè w oswa vizite sitwèb CDC a nan www.cdc.gov ak/oswa nan sitwèb Sèvis Sante Etidyan FIU nan: studenthealth.fiu.edu.

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STUDENT HEALTH SERVICES MENINGOCOCCALMENINGITIS INFORMATION Meningitis is an infection of the fluid of a person's spinal cord and the fluid that surrounds the brain. People sometimes refer to it as spinal meningitis. Meningitis is usually caused by a viral or bacterial infection. Knowing whether meningitis is caused by a virus or bacteriumis important because the severity of illness and the treatment differ. Viral meningitis is generally less severe and resolves without specific treatment, while bacterial meningitis can be severe and may result in brain damage, hearing loss, learning disability, or death. For bacterial meningitis, it is also important to know which strain of bacteria is causing the meningitis because antibiotics can prevent some types from spreading and infecting other people. Neisseria meningitidis (also called meningococcal meningitis) is the leading cause of bacterial meningitis.

What are the signs and symptoms of meningitis? Common Triad of symptoms: high fever, headache, and stiff neck. These symptoms can develop over several hours, or theymay take 1 to 2 days. Other symptoms include nausea, vomiting, skin rash, discomfort looking into light, confusion, and sleepiness.

How is meningitis diagnosed? Early diagnosis and treatment are very important. If symptoms occur, the patient should see a doctor immediately. The diagnos is is usually made in the laboratory from a sample of spinal fluid. The spinal fluid is obtained by performing a spinal tap, in which a needle is inserted into an area in the lower back where fluid in the spinal canal is readily accessible. Test results from the spinal fluid can identify if the cause is viral or bacterial and, if the latter, may help determine the selection of antibioticsmost effective in treatment.

Can meningitis be treated? Bacterial meningitis can be treated with a number of effective antibiotics. It is important, however, that treatment be started early in the course of the disease. Appropriate antibiotic treatment of most common types of bacterial meningitis should reduce the risk of dying from meningitis to below 15%, although the risk is higher among the elderly.

Is meningitis contagious? Yes, bacterial meningitis is highly contagious. The bacteria are spread through the exchange of respiratory and throat secret ions (i.e., coughing, kissing). Fortunately, none of the bacteria that cause meningitis are as contagious as things like the common cold or the flu, and they are not spread by casual contact or by simply breathing the air where a person with meningitis has been. However, sometimes the bacteria that cause meningitis have spread to other people who have had close or prolonged contact with a patient with meningitis. People in the same household or day-care center, or anyone sharing a bathroom or having direct contact with a patient's oral secretions (such as a boyfriend or girlfriend) would be considered at increased risk of acquiring the infection. People who qualify as close contacts of a person with meningitis caused by Neisseria meningitidis should receive antibiotics immediately to prevent them from getting the disease.

Are there vaccines against meningitis? Yes, there are vaccines that protect against some strains of Neisseria meningitidis but there are no vaccines to protect against viral forms. The vaccine against Neisseria meningitidis is sometimes used to control outbreaks of some types of meningococcal meningitis in the United States. Meningitis cases should be reported to state or local health departments to assure follow-up of close contacts and recognize outbreaks. The Advisory Committee on Immunization Practices (ACIP) recommends that all people at risk should receive one dose of the conjugate vaccine (Menactra) whenever possible. This is particularly true for college students who are under the age of 25 and live in close quarters with others or someone who has had his/her spleen removed; these are two groups who have an increased risk of acquiring meningococcal infection relative to other persons their age.

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SÈVIS SANTE ETIDYAN ENFÒMASYON SOU MENENJIT MENENGOKOKSIK Menenjit se yon enfeksyon likid ki nan mwèl epinyè yon moun ak likid ki antoure sèvo a. Pafwa yo rele li menenjit spinal. Anjeneral se yon enfeksyon viris oswa bakteri ki lakòz menenjit. Li enpòtan pou konnen si se yon viris oswa yon bakteri ki lakòz menenjit la paske gravite ak tretman maladi a diferan. Anjeneral menenjit viral mwen grav epi li rezoud san tretman presi, alòske menenjit bakteri a ka grav epi li ka lakòz domaj nan sèvo, pèt kapasite pou tande, andikap pou aprann, oswa lanmò. Pou menenjit bakteri A, li enpòtan pou konnen tou ki souch bakteri ki lakòz menenjit la, paske antibyotik yo ka anpeche sèten kalite souch pwopaje ak enfekte lòt moun. Se Neisseria meningitidis (ki rele menenjit menengokoksik tou) ki kòz prensipal menenjit bakteri.

Ki siy ak sentòm yon menenjit? Gwoup twa sentòm komen yo: gwo lafyèv, maltèt, ak kou rèd. Sentòm sa yo ka devlope pandan plizyè èdtan, oswa yo ka pran 1 a 2 jou. Lòt sentòm yo gen ladan kèplen, vomisman, gratèl leve sou po, malèz pou gade limyè, konfizyon, ak anvi dòmi.

Kijan yo fè dyagnostik menenjit? Li trè enpòtan pou fè dyagnostik ak tretman an bonè. Si sentòm yo rive, pasyan an dwe wè yon doktè san pèdi tan. Anjeneral yo fè dyagnostik la nan laboratwa apati yon echantiyon likid sefalorachidyen. Pou pran likid sefalorachidyen an, yo fè yon ponksyon lonbè, kote yo antre yon zegwi nan yon zòn anba do kote likid ki nan kanal mwèl epinyè a aksesib fasilman. Rezilta tès likid sefalorachidyen an ka idantifye si kòz la se viris oswa bakteri, epi, si se bacteri, yo ka ede detèmine chwa antibyotik ki pi efikas pou tretman an.

Èske yo ka trete menenjit? Yo ka trete menenjit bakteri avèk yon kantite antibyotik ki efikas. Men li enpòtan pou kòmanse tretman an byen bonè pandan maladi a. Tretman apwopriye ak antibyotik pou kalite menenjit bakteri ki pi kouran yo dwe diminye risk pou lanmò nan menenjit nan mwenske 15%, menmsi risk la pi gwo nan pami granmoun aje yo.

Èske menenjit atrapan? Wi, menenjit bakteri atrapan anpil. Bakteri yo pwopaje nan echanj respiratwa ak sekresyon gòj (sa vle di, nan touse, nan bo). Erezman, okenn nan bakteri ki lakòz menenjit yo pa atrapan tankou rim sèvo oswa grip, epi yo pa gaye nan kontak senp oswa tou senpleman si w respire lè kote te gen yon moun ki gen menenjit. Men, pafwa bakteri ki lakòz menenjit yo transmèt bay lòt moun ki te gen kontak deprè oswa kontak pandan anpil tan avèk yon pasyan ki gen menenjit. Moun ki nan menm kay oswa nan sant gadri, oswa nenpòt moun ki pataje yon twalèt oswa ki gen kontak dirèk ak sekresyon ki sot nan bouch yon pasyan (pa egzanp yon mennaj), ta gen ogmantasyon risk pou yo pran enfeksyon an. Moun yo konsidere kòm kontak deprè yon moun ki gen menenjit Neisseria meningitidis lakòz dwe resevwa antibyotik touswit pou anpeche yo pran maladi a.

Èske gen vaksen kont menenjit? Wi, gen vaksen ki pwoteje kont kèk souch Neisseria meningitidis men pa gen vaksen ki pwoteje kont fòm viral yo. Pafwa, yo itilize vaksen kont Neisseria meningitidis la pou kontwole deklanchman sèten kalite menenjit menengokoksik Ozetazini. Yo dwe rapòte ka menenjit yo bay depatman sante Eta oswa lokal yo pou asire yo swiv kontak deprè yo epi rekonèt lè gen deklanchman. Komite Konsiltatif sou Pratik Vaksinasyon (Advisory Committee on Immunization Practices, ACIP) rekòmande pou tout moun ki arisk resevwa yon dòz nan vaksen konjige (Menacra) a depi sa posib. Sa vrè espesylman pou etidyan kolèj ki poko gen laj 25 lane epi ki viv toupre lòt moun oswa yon moun yo te retire larat li; sa yo se de gwoup moun ki gen yon ogmantasyon risk pou trape enfeksyon menengokoksik parapò ak lòt moun ki gen menm laj ak yo.

FEV-09.27.16-p.4

29 SÈVIS SANTE ETIDYAN IMMUNIZATION DOCUMENTATION FORM/ FÒM DOKIMAN VAKSINASYON Instructions: Please write CLEARLY; illegible forms WILL NOT be processed. When entering a date on this form, please be sure to enter the month first, then the day, and then the year using the mm/dd/yyyy format (two digits each for both the month and day, and four digits for the year)./ Machaswiv: Tanpri ekri AKLÈ; nou p ap travay sou fòm ki pa lizib yo. Lè w ap mete yon dat sou fòm sa a, tanpri asire ou mete mwa a anpremye, apre sa jou a, answit ane a, epi w sèvi avèk fòma mm/jj/aaaa (de chif pou mwa a, ak de chif pou jou a, epi kat chif pou ane a). STUDENT NAME:/ NON ETIDYAN AN: DATE OF BIRTH:/ DAT NESANS: / / PANTHER ID:/ PANTHER ID:

REQUIRED FOR ALL STUDENTS Titer Dates: Lab Report rd yèm BORN AFTER 12/31/1956/ OBLIGATWA st mye nd yèm 3 Dose/3 must be attached/ Dat 1 Dose/1 Dòz 2 Dose/2 Dòz POU TOUT ETIDYAN KI FÈT APRE Dòz tès kantite antikò: Rapò 12/31/1956 Laboratwa a dwe tache 1. MMR (2 doses after 1st birthday & at least 28 days apart in 1971 or later)/ 1. MMR (2 dòz apre 1ye anivèsè nesans epi 28 jou entèval omwen an 1971 oswa pita) OR Measles (2 doses taken after 1968 or later)/ OSWA Lawoujòl (2 dòz ou pran apre 1968 oswa pita) / AND/ EPI Rubella (1 dose taken after 1969 or later)/ Ribeyòl (1 dòz ou pran apre 1969 oswa pita) / 2. Hepatitis B (OR check and sign waiver below)/ 2. Epatit B (OSWA tcheke ak siyen renonsyasyon ki anba a) / / / / / / 3. MCV4/ Meningococcal Meningitis (1 dose if taken after the age of 16 OR check and sign waiver below)/ 3. MCV4/ Menenjit Menengokoksik (1 dòz si ou pran l apre laj 16 lane OSWA tcheke epi siyen renonsyasyon ki anba a)  I have read the information about Hepatitis B and decline receipt of this vaccine./ Mwen te li enfòmasyon yo sou Epatit B epi mwen refize resevwa vaksen sa a.  I have read the information about MCV4 / Meningococcal Meningitis and decline receipt of this vaccine./ Mwen te li enfòmasyon yo sou MCV4 / Menenjit Menengokoksik epi mwen refize resevwa vaksen sa a. ______/___/______Student Signature (Note: Parent or legal guardian must sign if under 18 years of age)/ Siyati Date/ Dat etidyan an (Remak: Paran oswa gadyen legal la dwe siyen si li poko gen laj 18 lane)

______/___/______Healthcare Provider or Authorized Signature/ Founisè Swen Sante oswa Siyati Otorize Date/ Dat

RequiredOffice Stamp:/ So Biwo a Obligatwa:

Please submit this completed form at least FOUR WEEKS prior to registration date to [email protected]./ Tanpri soumèt fòm ki fin ranpli sa a KAT SEMÈN omwen anvan dat enskripsyon an nan [email protected]. OR/ OSWA Florida International University, Student Health Services:/ Florida International University, Student Health Services: Modesto Maidique Campus OR/ OSWA Biscayne Bay Campus SHS - 132 WUC - 307 11200 S.W.8 Street 3000 N.E. 151 Street Miami, FL 33199 North Miami, FL 33181/ 305-348-3336 (FAX) Biscayne Bay Campus 305-348-2688 (Voice)/ WUC - 307 Modesto Maidique Campus 3000 N.E. 151 Street SHS - 132 North Miami, FL 33181 11200 S.W.8 Street Miami, FL 33199 305-348-3336 (FAKS) 305-348-2688 (Vwa) FEV-09.27.16-p.5

31 Physical Examination Form/ Fòm pou Egzamen Fizik

FIU Embrace Postsecondary Comprehensive Transition Program/ Pwogram Tranzisyon Konplè Apre segondè FIU Embrace

Name:/ Non:______Date:/ Dat:______

Height:/ Wotè:______Weight:/ Pwa ______Pulse:/ Poul:______

Vision: R20/ Vizyon: R20 ______L20/ L20______

Corrected:/ Korije:  Yes/ Wi  No/ Non

Pupils: / Pipiy:  Equal/ Egal  Unequal/ Inegal

Normal Abnormal Findings (Check)/ (Please Specify)/ Dekouvèt Nòmal Anòmal Initials/Date/ MEDICAL/ MEDIKAL (Tcheke) (Tanpri, Presize) Inisyal/Dat Appearance/ Aparans  Eyes/Ears/Nose/Throat/  Je/Zòrèy/Nen/Gòj Hearing/ Odisyon  Lymph Nodes/ Gangliyon  Lenfatik Heart /Murmur/Rub/Gallop/  Kè/ Souf/Fwotman/Galo Pulse/ Poul  Lungs/ Poumon  Abdomen/ Vant  Genitourinary (males)/ Jenito-  irinè (gason) Skin/ Po  Musculoskeletal/ Miskiloeskeletik  Neck/ Kou  Back/ Do  Shoulder/Arm/ Zepòl/Bra  Elbow/Forearm/  Koudbra/Avanbra Wrist/Hands/Fingers/  Ponyèt/Men/Dwèt Hip/Thigh/ Hanch/Kwis  Knee/ Jenou  Leg/Ankle/ Janm/Cheviy  Foot/Toes/ Pye/Zòtèy 

32 Neurologic Exam/ Egzamen  Newolojik

33 The student has the following problems that may impact their educational experience.:/ Etidyan an gen pwoblèm annapre la yo ki ka afekte eksperyans nan edikasyon li:

Vision Problems/ Pwoblèm Yes/No (please circle one)/ If yes, please specify:/ Si Vizyon Wi/Non (tanpri ansèkle youn) se wi, tanpri bay presizyon: Hearing Problems/ Pwoblèm Yes/No (please circle one)/ pou tande Wi/Non (tanpri ansèkle youn) Speech Problems/ Pwoblèm Yes/No (please circle one)/ pou Pale Wi/Non (tanpri ansèkle youn) Language Problems/ Pwoblèm Yes/No (please circle one)/ Lang Wi/Non (tanpri ansèkle youn) Physical Problems/ Pwoblèm Yes/No (please circle one)/ Fizik Wi/Non (tanpri ansèkle youn) Social Problems/ Pwoblèm Yes/No (please circle one)/ Sosyal Wi/Non (tanpri ansèkle youn) Behavioral Problems/ Yes/No (please circle one)/ Pwoblèm Konpòtman Wi/Non (tanpri ansèkle youn) Cognitive Problems/ Pwoblèm Yes/No (please circle one)/ Koyitif Wi/Non (tanpri ansèkle youn)

This student has a health condition that may require emergency action at school/college, (e.g. seizures, allergies, diabetes, hypertension, stroke, heart problems, sickle cell, bone/joint etc.)?/ Etidyan sa a gen yon pwoblèm sante ki ka egzije aksyon dijans nan lekòl/kolèj, (pa egzanp kriz, alèji, dyabèt, tansyon wo, estwok, pwoblèm kè, anemi falsifòm, zo/jwenti elatriye)?

 Yes/ Wi  No/ Non

If yes, please specify below./ Si se wi, tanpri bay presizyon anba a.

(This form will be stored in the student’s Cumulative Health Folder and may be accessed by both University and health personnel.) Please complete FIU Immunization Documentation Form attached/(Y ap konsève Fòm sa a nan Dosye Sante Kimilatif Etidyan an epi ni pèsonèl Inivèsite a ni pèsonèl sante a ka jwenn aksè ladan.) Tanpri ranpli Fòm Dokiman Vaksinasyon FIU ou jwenn la a

Cleared without restriction:/ Otorize san restriksyon:______Date:/ Dat:______

34 Not Cleared: Cleared with specific restrictions (list):/ Pa Otorize: Otorize ak restriksyon presi (endike yo):

Cleared with recommendations for further evaluation or treatment for:/ Otorize ak rekòmandasyon pou plis evalyasyon oswa tretman pou:

SIGNATURE OF PHYSICIAN COMPLETING THIS FORM/ SIYATI DOKTÈ Date/ Dat KI RANPLI FÒM SA A

Physician Name (print)/ Non Doktè a (ekri ak lèt detache)

Physician Address:/ Adrès Doktè a:

Physician telephone number:/ Nimewo telefòn doktè a:

Personal Support Inventory

To be filled out by:

Parent/Family/Guardian and at least one Teacher

Envantè Sipò Pèsonèl

Moun ki dwe ranpli pati sa a se:

Paran/Fanmi/Gadyen ak yon pwofesè omwen

Personal Support Inventory/ Envantè Sipò Pèsonèl

To be completed by: Family Member or Guardian/ Moun ki dwe ranpli pati sa se: Manm Fanmi oswa Gadyen

Completed by:/ Ranpli pa: (Parent/Family Member/Guardian/Teacher)/ (Paran/Manm Fanmi/Gadyen/Pwofesè)

Please rate the applicant in the following areas. If you are unsure about a skill, please indicate by selecting the “?” box./ Tanpri evalye kandida a nan domèn annapre la yo. Si ou pa fin sèten osijè yon konpetans, pou endike sa, tanpri chwazi bwat “?” la).

Requires Needs Needs Needs complete moderate some minimal Completely ? assistance/ assistance/ assistance/ assistance/ independent/ Bezwen Bezwen Bezwen Bezwen Endepandan Independent Living Skills/ Konpetans pou Viv asistans asistans enpe asistans konplètman Endepandan konplè modere asistans minim Negotiating/finding way around campus and community/ Negosye/jwenn fason wout li sou kanpis la ak nan kominote a Ordering and purchasing from a restaurant, café, or store/ Plase kòmand ak achte nan yon restoran, kafe, oswa magazen Caring for personal hygiene and grooming needs/ Pran swen ijyèn pèsonèl ak swen aparans pèsonèl Handling personal affairs: laundry/ Jere zafè pèsonèl: lesiv Cooking/ Kwit manje Cleaning/ Netwayaj Managing personal belongings/ Jere afè pèsonèl Use of good judgment skills in an emergency/ Itilize konpetans bon jijman nan yon ijans Coping well with stress and anxiety/ Adapte byen nan estrès ak enkyetid Adjusting to new situations or environments/ Ajiste nan nouvo sitiyasyon oswa anviwònman Comments:/ Kòmantè yo:

Requires Needs Needs some Needs complete moderate assistance/ minimal Completely ? Social Skills and Communication/ Konpetans Sosyal ak assistance/ assistance/ Bezwen assistance/ independent/ Bezwen Bezwen enpe Bezwen Endepandan Kominikasyon asistans asistans asistans asistans konplètman konplè modere minim Communicating needs in an appropriate manner/ Kominike bezwen yo nan yon fason ki apwopriye Relating to others in a socially appropriate manner/ Kominike ak lòt moun nan yon fason ki apwopriye sosyalman Handling conflict with another person/ Jere konfli avèk yon lòt moun Respecting persons in authoritative positions/ Respekte moun ki nan pòs otorite Using a smart phone to communicate/ Sèvi ak yon smatfòn pou kominike Sending and receiving text messages/ Voye ak resevwa mesaj tèks Using email/ Sèvi ak yon adrès imèl Using social networking sites: Facebook, Twitter, etc./ Sèvi ak sit rezo sosyal yo: Facebook, Twitter, elatriye. Verbalizing and/or writing personal information: name, address, phone number, SSN, etc./ Pale pou di ak/oswa ekri enfòmasyon pèsonèl: non, adrès, nimewo telefòn, SSN, elatriye.

Comments:/ Kòmantè yo:

Personal Support Inventory/ Envantè Sipò Pèsonèl

To be completed by: Family Member or Guardian/ Moun ki dwe ranpli pati sa se: Manm Fanmi oswa Gadyen

Academic Skills/ Konpetans Akademik Requires Needs Needs Needs complete moderate some minimal Completely ? assistance/ assistance/ assistance/ assistance/ independent/ Bezwen Bezwen Bezwen Bezwen Endepandan asistans asistans enpe asistans konplètman konplè modere asistans minim Understanding the value of money/ Konprann valè lajan Handles money to make purchases/ Jere lajan pou fè acha Counting bills, change/ Konte biyè, monnen Staying within a budget/ Respekte yon bidjè Using a computer/ Sèvi ak yon òdinatè Navigating the Internet/ Navige sou entènèt Following verbal directions/ Swiv esplikasyon aloral Following written directions/ Swiv esplikasyon alekri Demonstrating motivation to learn and persist on new tasks/ Demontre motivasyon pou aprann epi pèsiste nan nouvo travay Maintaining and following a daily schedule/ Kenbe epi swiv yon orè chak jou Remembering and keeping up with due dates, assignments/ Sonje ak respekte dat limit, devwa Studying given information/ Etidye enfòmasyon yo bay

Has the applicant utilized assistive technology (voice recognition, dictation, iPad, etc.)?/ Èske kandida a te itilize teknoloji asistans (rekonesans vwa, dikte, iPad, elatriye)?

 Yes/ Wi  No/ Non

If yes, please list the type of technology the applicant is using:/ Si se wi, tanpri endike ki kalite teknoloji kandida a ap itilize:

 voice recognition/  alarms on device/ alam sou  ipad/iphone apps/ rekonesans vwa aparèy aplikasyon ipad/iphone

 laptop/ laptòp  Other: / Lòt:  Other: / Lòt:

40  calculator/ kalkilatris  Other: / Lòt:  Other: / Lòt:

 calendar on device/  Other: / Lòt:  Other: / Lòt: kalandriye sou aparèy

Personal Support Inventory/ Envantè Sipò Pèsonèl

To be completed by: Family Member/Guardian/Teacher/ Moun ki dwe ranpli pati sa se: Manm Fanmi/Gadyen/Pwofesè

Additional Comments: Please list/discuss any physical, intellectual, social, or emotional conditions that may need to be considered when planning a postsecondary experience.:/ Kòmantè Anplis: Tanpri endike/pale sou nenpòt kondisyon fizik, entelektyèl, sosyal oswa emosyonèl yo ta dwe konsidere nan planifikasyon yon eksperyans apre segondè.:

42 Student Questionnaire/ Kesyonè Etidyan

This section is to be hand-written by applicant and may include additional pages./ Kandida a dwe ekri seksyon sa a alamen epi li ka ajoute paj anplis ladan. Please indicate if a scribe is used./ Tanpri endike si w itilize yon moun pou ekri. This is an excellent opportunity to demonstrate writing skills, critical thinking skills and creativity!/ Sa se yon trè bon okazyon pou demontre konpetans nan ekriti, konpetans nan panse kritik ak kreyativite!

43 Student Questionnaire/ Kesyonè Etidyan

Why do you want to be an FIU Embrace PLUS student?/ Poukisa ou vle yon etidyan FIU Embrace PLUS?

Describe what skills you would like to learn in the following areas:/ Dekri ki konpetans ou ta renmen aprann nan domèn sa yo:

Independent Living / Viv Endepandan —

Employment / Travay —

Social / Sosyal —

44 Transportation/ Transpò

Do you have a:/ Èske w gen yon:

Learner’s Permit: Yes No/ Pèmi pou aprann kondi: Wi Non Driver’s License: Yes No/ Lisans Chofè: Wi Non

Have you ever:/ Èske w konn:

Flown independently?  Yes  No/ Pran avyon poukont ou?  Wi  Non

Used public transportation (taxi, bus, etc.) independently?  Yes  No/ Itilize transpò piblik (taksi, otobis, elatriye) poukont ou?  Wi  Non

Comment:/ Kòmantè:

What kind of jobs are you interested in after you leave?/ Ki kalite travay ki enterese w apre ou fini?

What do you like to do in your free time?/ Kisa ou renmen fè nan tan lib ou?

What is your favorite sport?/ Ki espò ou pi renmen?

45 What is your favorite musical group or favorite singer?/ Ki sa gwoup mizik ou pi renmen oswa chantè ou pi renmen?

Do you spend time with friends outside of school?  Yes  No/ Èske w pase tan ak zanmi andeyò lekòl?  Wi  Non If yes, what do you like to do with your friends?/ Si se wi, kisa ou renmen fè avèk zanmi ou yo?

Discuss two of your goals for the future upon completion of this program./ Pale sou de (2) objektif ou pou lavni lè w fini pwogram sa a. 1.

Please use this space to provide us with any additional information about yourself that you wish to share.:/ Tanpri itilize espas sa a pou w ban nou nenpòt enfòmasyon anplis ou vle pataje konsènan oumenm.:

FIU Embrace Postsecondary Comprehensive Transition Program

Student Recommendation Form

Pwogram Tranzisyon Konplè Apre segondè FIU Embrace

Fòm pou Rekòmandasyon Etidyan

48 Letters of Recommendation

Please submit 3 Letters of Recommendation from persons who have known the applicant for at least one year. The recommendations should represent each of the following:

1. Education 2. Vocational/Employment 3. Community Involvement

Make three copies of the Student Recommendation Form and give one copy to each of the evaluators for them to complete.

Letters must be submitted using the Student Recommendation Forms in this packet and must be returned with the application packet in sealed envelopes with the evaluator’s signature across the seal.

49 Lèt Rekòmandasyon

Tanpri soumèt 3 Lèt Rekòmandasyon moun ki te konnen kandida a pandan yon ane omwen. Rekòmandasyon yo dwe reprezante chak nan bagay sa yo:

1. Edikasyon 2. Pwofesyonèl/Travay 3. Patisipasyon Kominotè

Fè twa kopi Fòm Rekòmandasyon Etidyan an epi bay nan chak evalyatè yo yon kopi pou yo ranpli.

Yo dwe sèvi ak Fòm Rekòmandasyon Etidyan ki nan pake sa a pou soumèt lèt yo epi yo dwe voye yo tounen avèk pake aplikasyon an nan anvlòp kachte ki gen siyati evalyatè a atravè kote ki kachte a.

Student Recommendation Form/ Fòm Rekòmandasyon Etidyan

Postsecondary Comprehensive Transition Program/ Pwogram Tranzisyon Konplè Apre segondè To be completed by: Personal Reference/ Moun ki dwe ranpli pati sa se: Referans Pèsonèl

Recommendation for (applicant’s name):/ Rekòmandasyon pou (mete non kandida a):

The above named individual is applying for admission to the FIU Embrace Postsecondary Comprehensive Transition program at Florida International University. This program is designed to prepare students with cognitive and intellectual disabilities who desire a postsecondary experience on a college campus and require a strong system of support. These students are motivated young adults who have received extensive educational services in either public or private schools and would likely have considerable difficulty succeeding in a traditional college degree program. Students should have a strong desire to become an independent adult and must possess emotional stability and maturity to participate successfully in this program./ Moun ki endike anlè a ap aplike pou admisyon nan Pwogram Tranzisyon Konplè Apre segondè FIU Embrace nan Florida International University. Pwogram sa a fèt pou prepare etidyan ki gen andikap koyitif ak entelektyèl ki vle fè yon eksperyans apre segondè sou yon kanpis kolèj epi ki bezwen yon sistèm sipò ki solid. Etidyan sa yo se jèn adilt motive ki te resevwa anpil sèvis edikasyon swa nan lekòl piblik oswa nan lekòl prive epi ki t ap petèt gen anpil difikilte pou yo reyisi nan yon pwogram diplòm kolèj tradisyonèl. Etidyan yo dwe gen yon gwo dezi pou vin yon adilt endepandan epi yo dwe gen estabilite emosyonèl ak matirite pou yo patisipe avèk siksè nan pwogram sa a.

With the above information in mind, please answer the following questions to the best of your ability and complete a Personal Support Inventory (attached). Attach additional pages as needed. Please return this form to the applicant in a sealed envelope and sign across the seal. The applicant has agreed as part of the application process to waive access to the recommendation form. The applicant will submit all letters of recommendation as part of their completed Student Application Packet. Thank you for your assistance in this matter./ Pandan w ap teni kont de enfòmasyon yo ki anwo a, tanpri reponn kesyon annapre yo nan meyè fason ou kapab epi ranpli yon Envantè Sipò Pèsonèl (ou jwen la a). Ajoute paj anplis si sa nesesè. Tanpri voye fòm sa a tounen bay kandida a nan yon anvlòp ki kachte epi siyen atravè kote ki kachte a. Kandida a te dakò nan pwosesis aplikasyon an pou renonse a aksè nan fòm rekòmandasyon an. Kandida a ap soumèt tout lèt rekòmandasyon yo kòm yon pati nan Pake Aplikasyon Etidyan ki ranpli a. Mèsi pou asistans ou nan zafè sa a.

(Contact information of the individual completing the recommendation.)/ (Enfòmasyon pou Kontakte moun k ap ranpli rekòmandasyon an.)

Last Name/ Non Fanmi First Name/ Prenon MI/ Inisyal Dezyèm prenon

Organization Name/ Non Òganizasyon an Phone #/ # Telefòn

51 Address/ Adrès

City/ Vil State/ Eta Zip Code/ Kòd Postal

Email Address/ Adrès Imèl

52 Student Recommendation Form/ Fòm Rekòmandasyon Etidyan

Postsecondary Comprehensive Transition Program/ Pwogram Tranzisyon Konplè Apre segondè To be completed by: Personal Reference/ Moun ki dwe ranpli pati sa se: Referans Pèsonèl

1. How long have you known the applicant and in what capacity?/ 1. Depi konbyen tan ou konnen kandida a epi nan ki wòl?

2. Please describe why you feel the applicant would benefit from a postsecondary comprehensive transition experience./ 2. Tanpri dekri poukisa ou santi kandida a ta jwenn yon avantaj nan yon eksperyans tranzisyon konplè apre segondè.

3. How likely is it that the parent/family/guardian of this applicant will support the philosophy and goals of the FIU Embrace program?/ 3. Ki chans ki genyen pou paran/fanmi/gadyen kandida sa a soutni filozofi ak objektif pwogram FIU Embrace la?

 Unlikely  Likely  Quite Likely  Highly Likely/ Pa pwobab  Pwobab  Toutafè pwobab  Pwobab anpil

4. Please describe the strengths and challenges that the applicant may possess that will impact his/her candidacy for this program? (Use the back of this page or attach additional pages as necessary.)/ 4. Tanpri dekri pwen fò ak difikilte kandida a ka posede ki pral afekte kandidati li pou pwogram sa a? (Sèvi ak do paj sa a oswa mete lòt paj anplis si sa nesesè.)

53 Student Recommendation Form/ Fòm Rekòmandasyon Etidyan

Postsecondary Comprehensive Transition Program/ Pwogram Tranzisyon Konplè Apre segondè

To be completed by: Personal Reference/ Moun ki dwe ranpli pati sa se: Referans Pèsonèl

Please complete the following Personal Support Inventory. Should you not be familiar with the applicant in a particular area, please indicate by selecting the “?” box./ Tanpri ranpli Envantè Sipò Pèsonèl sa a. Si w pa abitye ak kandida a nan yon domèn espesyalman, tanpri endike chwazi bwat “?” pou w endike sa.

Requires Needs Needs Needs complete moderate some minimal Completely ? assistance/ assistance/ assistance/ assistance/ independent/ Bezwen Bezwen Bezwen Bezwen Endepandan Independent Living Skills/ Konpetans pou Viv asistans asistans enpe asistans konplètman Endepandan konplè modere asistans minim Negotiating/finding way around campus and community/ Negosye/jwenn fason wout li sou kanpis la ak nan kominote a Ordering and purchasing from a restaurant, café, or store/ Plase kòmand ak achte nan yon restoran, kafe, oswa magazen Caring for personal hygiene and grooming needs/ Pran swen ijyèn pèsonèl ak swen aparans pèsonèl Handling personal affairs: laundry/ Jere zafè pèsonèl: lesiv Cooking/ Kwit manje Cleaning/ Netwayaj managing personal belongings/ jere afè pèsonèl Asking for help or clarifications/ Mande èd oswa eklèsisman Asking questions when needed/ Poze kesyon lè li nesesè Use of good judgment skills in an emergency/ Itilize konpetans bon jijman nan yon ijans Coping well with stress and anxiety/ Adapte byen nan estrès ak enkyetid Adjusting to new situations or environments/ Ajiste nan nouvo sitiyasyon oswa anviwònman Comments:/ Kòmantè yo:

Requires Needs Needs some Needs complete moderate assistance/ minimal Completely ? assistance/ assistance/ Bezwen assistance/ independent/ Social Skills and Communication/ Konpetans Sosyal ak Bezwen Bezwen enpe Bezwen Endepandan asistans asistans asistans asistans konplètman Kominikasyon konplè modere minim Communicating needs in an appropriate manner/ Kominike bezwen yo nan yon fason ki apwopriye Relating to others in a socially appropriate manner/ Kominike ak lòt moun nan yon fason ki apwopriye sosyalman Handling conflict with another person/ Jere konfli avèk yon lòt moun Respecting persons in authoritative positions/ Respekte moun ki nan pòs otorite Using a smart phone/ Sèvi ak yon smatfòn Sending and receiving text messages/ Voye ak resevwa mesaj tèks Using email/ Sèvi ak yon adrès imèl Using social networking sites: Facebook, Twitter, etc./ Sèvi ak sit rezo sosyal yo: Facebook, Twitter, elatriye. Verbalizing and/or writing personal information: name, address, phone number, SSN, etc./ Pale pou di ak/oswa ekri enfòmasyon pèsonèl: non, adrès, nimewo telefòn, SSN, elatriye.

Comments:/ Kòmantè yo:

55 Postsecondary Comprehensive Transition Program/ Pwogram Tranzisyon Konplè Apre segondè To be filled out by: Personal Reference/ Moun ki dwe ranpli pati sa a se: Referans Pèsonèl

Requires Needs Needs some Needs minimal Completely complete moderate assistance/ assistance/ independent/ assistance/ assistance/ Bezwen enpe Bezwen ? Endepandan Academic Skills/ Konpetans Bezwen Bezwen asistans asistans minim konplètman Akademik asistans asistans konplè/ modere Understanding the value of money/ Konprann valè lajan Handles money to make purchases/ Jere lajan pou fè acha Counting bills, change/ Konte biyè, monnen Staying within a budget/ Respekte yon bidjè Using a computer for word processing/ Sèvi ak yon kompitè pou tretman tèks Navigating the Internet/ Navige sou entènèt Following verbal directions/ Swiv esplikasyon aloral Following written directions/ Swiv esplikasyon alekri Demonstrating motivation to learn and persist on new tasks/ Demontre motivasyon pou aprann epi pèsiste nan nouvo travay Maintaining and following a daily schedule/ Kenbe epi swiv yon orè chak jou Remembering and keeping up with due dates, assignments/ Sonje ak respekte dat limit, devwa Studying given information/ Etidye enfòmasyon yo bay

Give an explanation of the applicant’s reading abilities (and approximate grade level equivalent):/ Bay yon esplikasyon sou kapasite kandida a nan lekti (epi evalye apeprè ekivalan nivo klas la):

Give an explanation of the applicant’s writing /composition abilities (and approximate grade level equivalent):/ Bay yon esplikasyon sou kapasite kandida a nan redaksyon/konpozisyon (epi evalye apeprè ekivalan nivo klas la):

Give an example of the applicant’s math abilities (and approximate grade level equivalent):/ Bay yon egzanp sou kapasite kandida a nan matematik (epi evalye apeprè ekivalan nivo klas la):

56 Has the applicant utilized assistive technology such as voice recognition, dictation, iPad, etc.)?/ / Èske kandida a te itilize teknoloji asistans tankou rekonesans vwa, dikte, iPad, elatriye)?

 Yes  No/ Wi  Non

If Yes, please describe the type of technology used:/ Si se wi, tanpri dekri ki kalite teknoloji li itilize:

57 Student Recommendation Form/ Fòm Rekòmandasyon Etidyan Postsecondary Comprehensive Transition Program/ Pwogram Tranzisyon Konplè Apre segondè To be completed by: Personal Reference/ Moun ki dwe ranpli pati sa se: Referans Pèsonèl