Fillable Staff/Student Medical Clearance Form (University of Nebraska, Kearney)

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Staff/Student Medical Clearance Form (University of Nebraska, Kearney)

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File type: PDF

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Staff/Student Medical Clearance Form
SECTION 1 – For Completion by the STAFF/STUDENT
INSTRUCTIONS: Please complete Section I before giving this form to your medical provider. You will be required to
present this Medical Clearance Form in order to return to campus.
NOTE: The Medical Clearance Form must be completed and
submitted to the UNK Student Health office no more than
THREE days prior to returning to campus.
Name:
NUID:
If employee, UNK Supervisor (printed):
Department:
UNK email:
Alternative email (if applicable):
Address:
Telephone:
Areas/Countries of travel:
Dates of travel:
Medical Provider name:
Medical Provider telephone:
SECTION 2 – For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: The person listed is required to present this Medical
Clearance Form in order to return to campus.
NOTE: The Medical Clearance Form must be completed and
submitted to the UNK Student Health Office no more than
THREE days prior to returning to campus.
Is this person asymptomatic and allowed to return to campus?
YES
DATE RELEASED TO RETURN:
NO
DATE SHOULD RETURN FOR A FOLLOW-UP APPOINTMENT:
Additional medical notes (if applicable)
:
Healthcare Provider Signature:
Date:
Name of Healthcare Provider (use Stamp):
Type of Practice/ Medical Specialty:
Address:
Telephone number:
Please send this form to unkhealth@unk.edu
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StaffStudent Medical Clearance Form (University of Nebraska, Kearney)

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Completed 24 July 2020

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