COLLEGE OF ARTS & SCIENCES,
AND
EDUCATION
Office of Field Services and Professional Development Schools
2500 West North Avenue, Baltimore, Maryland 21216
Grace Hill Jacobs Room 709; (410) 951 – 3081
“Educator as a Reflective Facilitator of Learning”
Revised Fall 2015
INTERN’S HEALTH STATUS FORM
All prospective interns must have a physical examination prior to internship.
All prospective interns must have a chest x-ray or a Tuberculin skin test prior to internship.
Please complete the upper portion of this form and submit to your health practitioner. Once you have
the health practitioner’s signature, return the form to the Office of Field Services and Professional
Development Schools.
Name: ____________________________________________ SS#: ____________________________
Address: _____________________________________________________________________________
Telephone #: _________________________________ Email Address: __________________________
Date of Last Medical Examination: ________________________________________________________
Current Health Status: □ Excellent □ Good □ Poor
Comments that relate to any physical condition affecting internship:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of last chest x-ray or skin test: _____________________________
(must be within the last six (6) months)
Results: □ Positive □ Negative
_____________________________________________
Signature of Physician or Nurse
_____________________________________________
Title
_____________________________________________
Date
click to sign
signature
click to edit
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