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GOVERNMENT OF GUAM DEPARTMENT OF PUBLIC HEALTH AND

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GOVERNMENT OF GUAM
DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES
Division of Environmental Health, Health Certificate Program
Division of Public Health, Communicable Disease Control Program
HEALTH CERTIFICATE CLEARANCE APPLICATION
PLEASE COMPLETE BOX BELOW BEFORE PRESENTING THIS FORM TO YOUR HEALTHCARE PROVIDER
DEH-001 (Rev. 04/10/2018) HEALTHCARE PROVIDER CERTIFICATION ON REVERSE SIDE
Applicant’s Name: Citizenship:
Last First Middle
Birth Date: / / Social Security # - - Sex: Male Female
(Mo.) (Day) (Year)
Marital Status: Married Single Divorced Widowed Ethnicity/Nationality:
Contact Number: (Work) (Home) (Cell)
Mailing Address:
Residential Address:
Place of Employment: Location (Village):
Job Title:
I certify that the information provided above is true and accurate to the best of my knowledge:
SIGNATURE: Date:
NOTE TO APPLICANT: A valid photo I.D. (i.e. passport, driver’s license, authorization to work for alien workers, or other valid photo I.D.) must be presented when submitting this form to the department.
TYPE OF APPLICATION
NOTE TO HEALTHCARE PRACTITIONER: The above-named person is applying for DPH&SS Health Certificate in the occupation category checked below.
NEW APPLICANT
FOOD FACILITY (GFC):
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
COSMETOLOGY:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
• Professional License
COSMETOLOGY STUDENT:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
• Letter of enrollment from certified cosmetology school
COSMETOLOGY HELPER ONLY:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
TATTOO:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
INSTITUTIONAL (Nursing Home, Adult Care,
Child Care,
Correctional Facility):
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Physician’s Certification of Examination
LAUNDRY/DRY CLEANING:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Physician’s Certification of Examination
THERAPEUTIC MASSAGE:
• Two current passport sized photographs
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
• Professional License
THERAPEUTIC MASSAGE HELPER ONLY:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
RENEWAL APPLICANT
FOOD FACILITY (GFC):
• Do not use this form, please use the RENEWAL of Eating & Drinking
and/or Food Establishments form
COSMETOLOGY:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
• Professional License
COSMETOLOGY STUDENT:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
• Letter of enrollment from certified cosmetology school
COSMETOLOGY HELPER ONLY:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
TATTOO:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
INSTITUTIONAL (Nursing Home, Adult Care,
Child Care,
Correctional Facility):
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Physician’s Certification of Examination
LAUNDRY/DRY CLEANING:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Physician’s Certification of Examination
THERAPEUTIC MASSAGE:
• Two current passport sized photographs
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
• Certification of Examination
• Professional License
THERAPEUTIC MASSAGE HELPER ONLY:
• PPD skin test for TB within 6 months of applying – if POSITIVE,
perform chest x-ray and obtain clearance from CDC office, Room 118.
DEH-001 (Rev. 04/10/2018)
HEALTHCARE PROVIDER CERTIFICATION
NOTE TO ALL HEALTHCARE PROVIDERS: Please review the following instructions before completing this form.
PPD TEST RESULTS: Report the result of PPD skin test by giving the date the PPD was given, the date read, and the
measurement in millimeters (mm).
Section A: This section is to be completed only if the applicant is free of communicable diseases, including those for
which screening is specified.
Section B: This section is to be completed only if the applicant is not free of communicable diseases, including those for
which screening is specifically indicated. Applicants with positive PPD skin tests must be referred by their
physician to their reference x-ray facility to have a routine chest x-ray performed to screen for active
tuberculosis. This x-ray must be read and interpreted by a licensed radiologist and a written report prepared
for the physician.
COMMUNICABLE DISEASE CONTROL (CDC) CERTIFICATION: CDC certification is to be signed ONLY by the
CDC Tuberculosis Program Coordinator of the department upon completion of all the reporting requirements and after the
CDC physician’s medical evaluation certifies that the applicant has completed/or is currently under treatment and has been
certified as non-contagious
.
WARNING: THIS CLEARANCE IS NOT VALID UNLESS THE PRINTED NAME AND SIGNATURE OF THE
PHYSICIAN/AUTHORIZED PERSON (INCLUDING TITLE) ARE PRESENT IN SECTION “A” OR “B” ALONG WITH
THE PHYSICIAN’S/AUTHORIZED PERSON’S STAMP AND THE REQUIRED MEDICAL INFORMATION.
Applicant’s Name:
PPD TEST RESULT: Date Given: _________________, Date Read: ________________, Reading: ___________ (mm)
PLEASE CHECK AND COMPLETE EITHER SECTION “A” OR “B” AS APPROPRIATE
I have performed the health screen tests indicated on the front of this form and find the applicant:
A
is free of the communicable diseases for which screening
is indicated above for the occupation in
which the
applicant desires employment.
________________________________________________
Physician’s or other Authorized Name (Print and Stamp)
________________________________________________
If not Physician, Title (Print and Stamp)
________________________________________________
Signature Date
This Applicant should go directly to the DIVISION OF
ENVIRONMENTAL HEALTH at the Department of Public
Health and Social Services in Mangilao to continue
processing.
COMMUNICABLE DISEASE CONTROL
CERTIFICATION
FOR COLUMN “B” TO THE RIGHT:
The applicant may may not
Be employed in the occupation indicated above as of this
Date:
Signature: DPH&SS, CDC Certifying Officer
B
is NOT free of the communicable disease for which
screening is indicated above for the
occupation in which
the application desires employment.
Attached are the copies of the following indicated documents:
Physical Examination (Health Screen) Form
A written report of laboratory test results.
A copy of the official Radiological Report.
Other (Specify) _________________________________
__________________________________________________
Physician’s or Other AUTHORIZED Name (Print and Stamp)
__________________________________________________
If not Physician, Title
(Print and Stamp)
__________________________________________________
Signature Date
This Applicant should go directly to the COMMUNICABLE
DISEASE CONTROL PROGRAM, ROOM 118, at the Dept. of
Public Health and Social Services in Mangilao to continue
Processing.
FOR DEH USE ONLY:
Received by: ______________________________________
Date: ________________________________________
NAME
HOME ADDRESS:
MAILING ADDRESS:
DOB:
ETHNICITY:
PHONE NUMBERS:
(Home/Work/Mobile)
YES NO DOES THE PATIENT HAVE A HISTORY OF:
Yes
No Type: ____________________
Cancer
Hepatitis
Yes No
Kidney Disease Yes No On dialysis? Yes No
Rheumatoid Arthritis (Joint Pain) Yes No
HIV/AIDS Yes No On medications? Yes No
Other/Note: _____________________________________
_
the Radiologist' recommendations before referral to Public Health for clearance*
Date of CXR: ___________ Normal
Abnormal
Comments: _______________________________________________________
(if applicable, copy of report
Normal
Abnormal
3HP INH RIF Other: _________________________
Date Started:_______________Date Completed:_________________
Refused Date Refused __________Reason for refusing:___________________________
Adverse reactions to LTBI therapy? Yes No
By signing this form, I,___________________________________(Name of licensed provider (MD/NP/PA)),
am certifying that I have ruled out active TB and the patient is cleared for work/school.
Date
(valid 90 days)
Revised and effective: August 01, 2020
Chest pain
TUBERCULOSIS (TB) EVALUATION FORM
PLEASE SUBMIT FOR CLEARANCE REQUEST FOR PATIENTS HAVING POSITIVE TB INFECTION
PPD SKIN TEST
IGRA TEST
Has the patient been exposed to active TB in the last (2) years? Yes No
SYMPTOMS ≥ 2 WEEKS
Date read: ___________ Result:_____________
Reading: ________mm
PHYSICIAN SIGNATURE/STAMP
NAME OF CLINIC
Date given:___________ Test Type: ____________ Result: __________________________
Date given:___________
Shortness of breath
Hoarseness
Chest X-ray
(copy of report MUST
be
attached)
LTBI TREATMENT:
Cough
Fever
Weight loss
Night sweats
Fatigue
_____
DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES
BUREAU OF COMMUNICABLE DISEASE CONTROL
TUBERCULOSIS/HANSEN'S DISEASE CONTROL PROGRAM
520 West Santa Monica Avenue, Dededo, Guam 96929
Phone: (671) 687-4388 / Email: tb.program@dphss.guam.gov
CLEAR FORM
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GOVERNMENT OF GUAM DEPARTMENT OF PUBLIC HEALTH AND

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Completed 24 May 2021

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