Fillable UH Hilo HEALTH CLEARANCE FORM

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UH Hilo HEALTH CLEARANCE FORM

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University of Hawai’i at Hilo – Student Medical Services FALL 20 _______ SPRING 20 _______
200 W. Kawili St. Campus Center Rm. 212 Hilo, HI 96720
Phone: 808.932.7369 Fax: 808.932.7368 File Drop: www.hawaii.edu/filedrop Recipient: uhhsms@hawaii.edu
UNIVERSITY OF HAWAI’I AT HILO – HEALTH CLEARANCE FORM
Printed Name & Title ______________________________________ Date ______________ Telephone No. ______________________
Licensed Medical Provider Signature ______________________________________________ Official Stamp _____________________________
This form may be rejected if it is not fully completed and signed in both sections by licensed medical provider in the United States. Revised 6/13/18
Student Instructions: 1) Complete box 1 by filling in your personal information.
2) Information in boxes 2 & 3 must be completed by a licensed medical provider in the United States.
3) Health clearances must be submitted as soon as possible, failure to do so may result in disenrollment
from courses.
4) By filling out this form, you authorize the Health Clearance form to be sent to the
University of Hawai’i system and to be shared within the University of Hawai’i system.
Medical Provider Instructions: 1) Complete boxes 2 & 3. Be sure to sign and stamp each section you complete.
TUBERCULOSIS CLEARANCE REQUIREMENTS
MEASLES MUMPS RUBELLA (MMR) CLEARANCE REQUIREMENTS (One of the following):
Proof of one dose of the Measles (Rubeola) vaccine, and one dose of Measles/ Mumps/ Rubella (MMR) vaccine, OR
Proof of two dose of the Measles/ Mumps/ Rubella (MMR) vaccinations, OR
Positive Measles Mumps Rubella (MMR) IgG blood test report if student had diseases, or if vaccines were administered, but no record is available
(Licensed medical provider in the United States must review and sign report below), OR
Student was born before 1957.
Note: Vaccines should be one month apart, given on or after January 1, 1968; and/ or after the student’s first birthday.
Box 4: Licensed Medical Provider’s
Use Only:
DATE OF IMMUNIZATION
VACCINE
#1
#2
Measles OR
/ /
MMR Required
Mumps Measles Rubella (MMR)
/ /
/ /
Box 1: STUDENT INFORMATION
Name ____________________________________________________________________ UH Number or Username _________________________
Last Name First Name M.I.
Mailing Address _______________________________________________________ City _______________ State ______ Zip ________________
Email Address _________________________________________________ Daytime Phone _____________________ Birth Date _____/_____/_____
Box 2: Licensed Medical Provider’s Use Only: *Please attach screening form
I have evaluated the individual named above using the process set out in the DOH TB Clearance Manual dated 2/10/17 and determined that the individual meets State of
Hawaii criteria for TB Clearance as defined in section 11-164.2-2, Hawaii Administrative Rules.
Screening for post-secondary schools (TB Document)
Negative TB Risk Assessment & Symptom Screen. Date _____/_____/_____
Negative TB Test or IGRA (QFT). Date _____/_____/_____
Negative CXR. Date _____/_____/_____
Signature and/or Unique Stamp of Licensed Medical Provider: _____________________________
Printed Name of Licensed Medical Provider: _________________________________________
Healthcare Facility: _________________________________________________
Date: ____________________
Note: This TB clearance provides a reasonable assurance that the individual listed on this form was free from tuberculosis disease at this time of the exam. This form
does not imply or guarantee or protection from future tuberculosis risk for the individual listed.
TITER TEST
Attach signed (by licensed
medical provider) photocopy of
the positive IgG Blood Test
Results for Measles, Mumps,
Rubella (MMR)
PERSONAL HEALTH CLEARANCE INFORMATION – I hereby authorize the release of my health clearance information to other campuses within the University of
Hawai’i System to be used for enrollment and transfer purposes between UH campuses.
_________________________________________________________________________________________________________
SIGNATURE OF STUDENT (Parental signature required if under 18) DATE
Authorization and Consent for Treatment of Minors
To be completed by Parent or Guardian if the student will be 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 at Hilo Student Medical Services
(hereafter UHHSMS), hereby voluntarily and knowingly, authorize and give my express consent to the UHHSMS 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 UHHSMS staff.
___________________________________________________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE
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DOH TB Control Program DOH TB Clearance Manual 7/18/2017
- 13 -
TB Document G: State of Hawaii TB Risk Assessment for Adults and Children
Hawaii State Department of Health
Tuberculosis Control Program
1. Check for TB symptoms
If there are significant TB symptoms, then further testing (including a chest x-ray) is required
for TB clearance.
If significant symptoms are absent, proceed to TB Risk Factor questions.
□ Yes
□ No
Does this person have significant TB symptoms?
Significant symptoms include cough for 3 weeks or more, plus at least one of the following:
□ Coughing up blood □ Fever □ Night sweats
□ Unexplained weight loss □ Unusual weakness □ Fatigue
2. Check for TB Risk Factors
If any “Yes” box below is checked, then TB testing is required for TB clearance
If all boxes below are checked “No”, then TB clearance can be issued without testing
□ Yes
□ No
Was this person born in a country with an elevated TB rate?
Includes countries other than the United States, Canada, Australia, New Zealand, or
Western and North European countries.
□ Yes
□ No
Has this person traveled to (or lived in) a country with an elevated TB rate for four weeks
or longer?
□ Yes
□ No
At any time has this person been in contact with someone with infectious TB disease?
(Do not check “Yes” if exposed only to someone with latent TB)
□ Yes
□ No
Does the individual have a health problem that affects the immune system, or is medical
treatment planned that may affect the immune system?
(Includes HIV/AIDS, organ transplant recipient, treatment with TNF-alpha antagonist, or
steroid medication for a month or longer)
□ Yes
□ No
For persons under age 16 only: Is someone in the child’s household from a country with
an elevated TB rate?
Provider Name with Licensure/Degree:
Assessment Date:
Person's Name and DOB:
Name and Relationship of Person Providing
Information (if not the above-named person):
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UH Hilo HEALTH CLEARANCE FORM

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Completed 25 December 2019

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