Information Request:First and Last Name:Email Address: College or University: Q1 Does your institution have a student health clinic located on campus where nurses or doctors provide medical services, or not?o Yes o No Q2 Does your institution contract with an off-campus medical clinic to provide medical services to students off campus? o Yes, please provide the name and address: o No Q3/Q4 What was the total budget in 2012 and 2017 for medical services for the student health clinic? Please do not include budget for counseling/mental services. Enter the amount in dollars using numbers only.o 2012 budget:o 2017 budget: Q5/Q6 What was the total budget in 2012 and 2017 for counseling and mental health services? Please do not include budget for medical services at the student health center. Enter the amount in dollars using numbers only.o 2012 budget:o 2017 budget: Q7 We are seeking a copy of your institution’s chargemaster sheet or a comprehensive list of fees for all products, procedures, and services available at the student health clinic. Please upload here or email to email@example.com Q8 Does your institution charge a student health fee? If so, please identify the amount per semester in 2017. If fees vary depending on student status, please detail the fee amount for each type of student. Q9 How many full-time equivalent physicians and nurses did your institution have on staff for medical services in 2012 and 2017?o Physicians in 2012: o Nurses in 2012: o Physicians in 2017: o Nurses in 2017: Q10 Does your institution fully own and operate the on-campus health center, or not? If not, what is the name of the group that the university contracts with (i.e. medical school, hospital, private physician group, urgent care clinic, etc.)?o Yes o No, please name group: Q11 What are the clinic’s hours of operation on weekdays and weekends during the academic year? Q12 Does your institution have a pharmacy located on campus, or not? o Yes o No Q13 Does your institution require students have health insurance?o Yeso No Q14 Does your institution offer students its own health insurance plan? o Yes o No Q15 Does your institution require medical history forms and/or immunization history forms from students as a condition of enrollment? If yes, which ones?o Yes, please specify which forms: o No Q16 Thank you for your time! Do you have anything else you’d like to mention about student health services at your institution?