Fillable HEALTH IMMUNIZATION CLEARANCE FORM

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HEALTH IMMUNIZATION CLEARANCE FORM

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HEALTH IMMUNIZATION CLEARANCE FORM
The State of Hawai‘i Department of Health (DOH) Hawai‘i Administrative Rules, Title 11 (Chapter 157 and 164.2) requires certain
health requirements be met for attendance to a post-secondary institution. Registration is not allowed until all health clearances are met
and submitted to the Admissions and Records Office. Health clearances must bear the signature of the practitioner, stamp, or imprinted
name of the department or practitioner or name of licensed facility. A practitioner is a physician, advanced practice registered nurse
(APRN), or physician assistant (PA) licensed to practice in the United States. This form may be rejected if it is not fully completed
and signed in both sections by a U.S. licensed medical practitioner
.
NAME:
Birth Date:
Print Student Last Name, First Name MI
UH ID:
Are you an international student:
Phone Number:
Address
:
Yes
No
TUBERCULOSIS (TB) CLEARANCE
I have evaluated the individual named above using the process set out in the State of Hawai‘i DOH TB Clearance Manual and determined that the
individual does not have TB disease as defined in section 11-164.2-2, Hawai`i Administrative Rules.
Positive test for TB infection, and
Negative TB risk assessment
TB Screening Date:
____/____/______________
negative chest x-ray
Negative IGRA (QuantiFERON / Negative test for TB infection
T-SPOT) blood test
This TB clearance provides a reasonable assurance that the individual was free from tuberculosis disease at the time of the exam. This does not
imply any guarantee or protection from future tuberculosis risk.
Date
:
___/___/__________
Healthcare Facility:
Dose 1 Date:
___/___/_______
Dose 2 Date: ___/___/________
Born in U.S. before 1980
Immunizations shall include the complete date the vaccine was administered. All immunizations must meet the minimum ages and
minimum intervals between doses. For a Religious exemption, see the Admissions and Records Office for the appropriate exemption
form. For Medical Exemptions, see a U.S. licensed practitioner. Please refer to the Hawai'i Department of Health for guidelines on
Immunization Requirements and Exceptions to these requirements.
1) Tdap (Tetanus-diphtheria-acellular pertussis) 1 dose: Date: ___/___/_______
Signature or Stamp of Practitioner:
Print Name of Practitioner:
IMMUNIZATION
Date:
___/___/___________
Healthcare Facility:
TB
TB15 MR VC TD MCV GOAMEDI SOAHOLD OnBase
Revised 7/22/2020 UHSYS-SA p. 1 of 2
Signature of Practitioner:
Note: Valid Tdap dose must be administered on or after 10 years of age. Do not confuse with DTaP (administered to children 0-6 years of age).
Tdap was licensed for use in the U.S. in 2005. Doses recorded as “Tdap” with an administration date in the U.S. prior to 2005 should not be counted.
Printed Name/Stamp of Practitioner:
Dose 1 Date: Dose 2 Date:
2) MMR (Measles,
Mumps, Rubella) 2 doses:
Note: Mumps titers are no longer accepted for proof of immunity
History of Varicella disease or Herpes Zoster
Exceptions:
Exceptions:
Born before 1957
____
/____/_______
____
/____/________
____
/________
Office Use Only:
Addt'l Notes:
3) Varicella (chickenpox) 2 doses:
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
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COMPLETE PAGE TWO OF THIS FORM IF APPLICABLE
HEALTH CLEARANCE FORM (page 2)
NAME: Birth Date: UH ID:
Print: Student Last Name, First Name MI
COMPLETE ONLY IF STUDENT WILL BE LIVING IN ON-CAMPUS HOUSING
Yes No Student will be residing in on-campus housing
Yes No This is the student's first time at this institution and is 21 years or younger
If yes to both, please provide Meningococcal Conjugate (MCV) immunization date: _____/_____/__________ (at least 1 dose,
on or after the age of 16 years)
Signature or Stamp of Practitioner: Date:
Print Name of Practitioner: Healthcare Facility:
COMPLETE ONLY IF STUDENT (UNDER THE AGE OF 18) WILL BE SELECTING TO RECEIVE
HEALTHCARE SERVICES FROM ON-CAMPUS HEALTH FACILITY
(UH Mānoa, UH Hilo, Maui College, Leeward CC)
To be completed by Parent or Legal Guardian if the student is under the age of 18 when seeking health services from the
University.
I, the parent/legal guardian of (print student’s name), in consideration of
the services rendered by the University of Hawai’i Health Center, hereby voluntarily and knowingly, authorize and give my
express consent to the Health Center for the administration of TB tests, immunizations, medical treatment for illnesses or
injuries, and emergency care to the above-named student as deemed necessary by the Health Center staff.
Parent/Legal Guardian Signature: Date:
Print Last Name, First Name:
Revised 7/22/2020 UHSYS-SA p. 2 of 2
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HEALTH IMMUNIZATION CLEARANCE FORM

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Completed 18 April 2021

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