This information is treated confidentially and does not become a part of your academic records. All students and employees of the
University of Guam are required to complete and submit the health clearance form with immunization records from your clinic.
Please type or print answers in English using BLACK OR BLUE INK.
UOG STUDENT ID #:_______________
HEALTH CLEARANCE FORM
DATE OF BIRTH:
/
GENDER: F M
NAME:
MAILING ADDRESS:
Street / P.O. Box
Ci ty
State Zip Code
PHONE: (H)( )
(W)( )
Previously enrolled at UOG/GCC: No Y es
Year:
PHONE: (H)( ) (CELL)( )
Area Code Area Code Area Code
DATE:
revised 11/201 J5G
PLEASE DO NOT SEND YOUR MEDICAL FORMS THROUGH EMAIL.
Mail or fax form to:
University of Guam
Student Health Services
303 University Drive, Guam 96913
Tel: (671) 735-2225/6 Fax: (671) 734-4651
Email: uogstudenthealth@triton.uog.edu
URGENT DEADLINES TO SUBMIT HEALTH FORMS:
FALL SEMESTER: LAST FRIDAY OF JUNE
SPRING SEMESTER: LAST FRIDAY OF NOVEMBER
SUMMER SEMESTER: LAST FRIDAY OF APRIL
/
Area Code
First
Middle
ANY OTHER NAMES USED ON OTHER REQUIRED DOCUMENTS
Last(Family Name)
First
Middle
Last(Family Name)
EMAIL ADDRESS:
STUDENT SIGNATURE:
EMAIL ADDRESS:
Note: Information regarding disability, voluntarily given or inadvertently received, will not adversely affect any admissions
decision. If you should require special services because of your disability, you may notify the University Health Nurse or Enrollment
Management and Student SƵĐĐĞƐƐ Dean. This voluntary self-identification allows the University of Guam to prepare appropriate support
services to facilitate your learning. This information will be kept in strict confidence and has no effect on your admission to the University of
Guam.
DO YOU HAVE ANY SIGNIFICANT MEDICAL CONDITIONS OR DISABILITIES THAT WOULD LIMIT PARTICIPATION IN ACADEMIC AND/OR
PHYSICAL ACTIVITIES?
Please specify:
Drug allergy:
Other allergies:
EXPECTED TERM OF ENROLLMENT:
Year: Semester:
IN CASE OF EMERGENCY NOTIFY: NAME:
Semester:
RELATIONSHIP:
(W)( )
(CELL)( )
STUDENT INFORMATION
Area Code
PLEASE CHECK ONE:
NEW STUDENT:
RE-ENTRY:
GRADUATE SCHOOL:
Area Code
*PLEASE NOTE: IF FRIDAY FALLS ON A HOLIDAY, PLEASE SUBMIT YOUR FORMS ON THURSDAY*
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The University of Guam requires all newly entering students to be immunized against MEASLES and RUBELLA (GERMAN MEASLES). This
medical requirement will be strictly monitored and enforced due to the increasing occurrence of measles in adults throughout the Pacific
and United States. Under Guam Public Law Article 3, Chapter 3, §3322. Vaccination and Immunaztion, no student shall be permitted to
attend school unless evidence is presented, indicating that the student is free from any communicable diseases, and has had all the required
vaccinations or immunzations. (Please use BLACK or BLUE ink)
REQUIRED IMMUNIZATIONS – MEASLES/MUMPS/RUBELLA (MMR), PPD
To avoid unnecessary vaccination of MMR, please refer back to your old shot records first for two (2) doses of MMR. You may obtain a copy of your shot
records from your clinic, elementary, middle, or high school, or previous college attended. Two (2) doses are required and must have be given at least 28 days
apart for students born after 1956 (CDC). This requirement is to be waived if: 1) the student was born on or before 1957 or 2) if a physician has documented the
diagnosis of measles in the past or 3) Serologic evidence of immunity is provided. Complete one of the following:
Measles (§)
Mumps (§)
BORN AFTER 1956)
Rubella (§)
PPD Date Given ____________ Date Read ____________ Results(mm) ____________ Clinic ______________________
If PPD is positive (+): Obtain a Latent Tuberculosis Infection (LTBI) form and have it filled out by a physician. Attach Chest X-Ray Report
(must be within 4 years) and proceed to Department of Public Health & Social Services in Mangilao, Tuberculosis Department to
obtain your Public Health clearance. Office Hours for Public Health (TB Dept.): Mon- Thurs: 8:00 AM - 5:00 PM | for more info: call 735-7157
Dates of immunizations must be indicated and signed by provider or immunization record submitted with Medical History Form.
All corrections made, must be initialed by provider (NO-WHITE OUTS ACCEPTED).
Date of Last Immunization
Phone Number/Email
Name MD/Nurse (PRINT/STAMP/SIGN)
Date
LAST FIRST MIDDLE
STUDENT HEALTH SERVICES
STUDENT'S NAME:
UOG ID#:
DATE OF BIRTH:
or Antibody Titer Results: Circle One
Measles date and result:
Rubella date and result:
Mumps date and result:
Pos / Neg
Pos / Neg
Pos / Neg
PART III – MENINGOCOCCAL, TETANUS/DIPHTHERIA/PERTUSSIS, AND VARICELLA (OPTIONAL)
Although not required for enrollment, these vaccines are recommended.
Varicella
Disease Date:
Titer date and result: +/-
Dose #1 and Dose #2 dates:
Tetanus, Diphtheria, Pertussis:
One dose of Tdap for all students, regardless of
interval since last Td booster
Td OR Tdap Date
of most recent dose:
Td primary series dates
Meningococcal Quadrivalent vaccine date(s):
Dates of other vaccines highly recommended
Hepatitis A and Hepatitis B:
Polio:
Human Papilloma Virus Vaccine:
S
tu
dents must show valid documentation of TB skin test result conducted within six (6) months prior to entry into the University of
Guam. NEGATIVE and four (4) day readings are NOT accepted.
revised 11/201 J5G
Clinic/Address
PLEASE DO NOT SEND YOUR MEDICAL FORMS THROUGH EMAIL.
Mail or fax form to:
University of Guam
Student Health Services
303 University Drive, Guam 96913
Tel: (671) 735-2225/6 Fax: (671) 734-4651
Area Code( )
Email: uogstudenthealth@triton.uog.edu
click to sign
signature
click to edit
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