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University of Hawai’i
University Health Services Mānoa
1710 East West Road, Honolulu, Hawai’i 96822
Phone 808-956-8965 Fax 808-956-3583
Secure email via File Drop: www.hawaii.edu/filedrop
Recipient: UHSM
Dear Entering Student:
Welcome to University of Hawai‘i at Mānoa! The University Health Services Mānoa (UHSM) is located on
campus near the Kennedy Theater. A professional staff of physicians and nurses provide for the health needs
of the students. UHSM has a general medical clinic for ambulatory care and specialty clinics by appointment,
including women’s health, sports medicine, dermatology, psychiatry, and nutritional counseling. We have a
laboratory and pharmacy. Please visit our web site at http://www.hawaii.edu/shs to schedule an
appointment or learn more about us.
HEALTH CLEARANCE REQUIREMENTS (Hawai‘i Administrative Rules, DOH Title 11, Chapter 157)
The State of Hawai‘i mandates that certain health requirements be met for entrance to post-
secondary educational institutions. All students, including faculty/staff enrolled as students, must comply
with health clearance requirements by completing the Health Clearance Form and Immunization Record and
returning it by mail, fax or secure email to the Health Services. Please follow instructions for Tuberculosis
Clearance and Immunization Requirements carefully. Observe the deadline - You may not attend classes
until you have received health clearance.
1) TUBERCULOSIS (TB) CLEARANCE (REQUIRED)
• A TB Clearance needs to be obtained within twelve months prior to your start date or obtained on or
after age sixteen. International Students may submit a IGRA or Quantiferon blood test and the clearance
statement must be completed by a U.S. licensed physician, nurse practitioner or physician assistant. TB
skin tests done outside the US are not acceptable. If test is positive, a chest x-ray is required, but must
be done in the US. Foreign x-rays are not accepted.
2) IMMUNIZATION CLEARANCE (R
EQUIRED)
• MEASLES, MUMPS, AND RUBELLA (MMR) VACCINES: Two MMR vaccines are required.
o If you are born before 1957, you are exempt from the MMR requirements.
o Titers are no longer acceptable.
• TDAP (TETANUS, DIPHTHERIA, ACELLULAR PERTUSSIS) VACCINE: Must be administered on or after
age 11.
• VARICELLA (CHICKEN POX) VACCINE: Two Varicella vaccines are required.
o If you had Varicella disease or infection, your U.S. Licensed Healthcare Provider must
document date of disease or infection and sign.
o If you were born in the U.S. before 1980 you are exempt from the Varicella requirements.
• MENINGOCOCCAL CONJUGATE VACCINE (A, C, Y, W-135) is required for first-year college students
living in on-campus housing who are age 16 through 20. You will not be allowed to check into your
on-campus housing without documentation.
3) HIGHLY RECOMMENDED VACCINATIONS (PLEASE DISCUSS WITH YOUR HEALTHCARE PROVIDER):
Serogroup B Meningococcal (MenB) Polio Human Papillomavirus Hepatitis A and B
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ FOR OFFICE USE ONLY ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
TB TB15 MR VC TD GOAMEDI SOAHOLD OnBase
Revised 12/03/19 UHSYS-SA p. 1 of 2
HEALTH 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: UH ID:
Print Last Name, First Name MI
Student’s Signature: Date:
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.
TB Screening Date: Negative TB risk assessment
Negative test for TB infection
Positive test for TB infection, and negative chest x-ray
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.
Signature or Stamp of Practitioner: Date:
Print Name of Practitioner: Healthcare Facility:
IMMUNIZATION
Immunizations shall include the complete date the vaccine was administered, recorded as month/day/year. All immunizations must
meet minimum ages and minimum intervals between doses. For Religious exemption, see the Admissions and Records Office for
appropriate exemption form. For Medical Exemption, see a U.S. licensed practitioner.
MMR (Measles, Mumps, Rubella) 2 doses: Date:___/___/_______ Date: ___/___/_______
Born before 1957 (exempt from MMR)
Varicella (chickenpox) 2 doses: Date: ___/___/_______ Date: ___/___/_______
History of Varicella disease Date: ___/___/_______
Born in U.S. before 1980 (exempt from Varicella)
Tdap (Tetanus-diphtheria-acellular pertussis) 1 dose: Date: ___/___/_______
Signature of Practitioner: Date:
Printed Name/Stamp of Practitioner: Healthcare Facility:
Fall 20
Spring 20
Summer 20
Page 2 of 7
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Revised 12/03/19 UHSYS-SA p. 2 of 2
COMPLETE PAGE TWO OF THIS FORM IF APPLICABLE
HEALTH CLEARANCE FORM (page 2)
NAME: Birth Date: UH ID:
Print Last Name, First Name MI
COMPLETE ONLY IF STUDENT WILL BE LIVING IN ON-CAMPUS HOUSING
Yes No Residing in on-campus dorm
Yes No First-year student age 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:
AUTHORIZATION
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 and to comply with the State of Hawai‘i Department of
Health (DOH) Hawai‘i Administrative Rules, Title 11 (Chapter 157 and 164.2).
Student’s Signature: Date:
Parent’s Signature if student age 17 or younger: Date:
Page 3 of 7
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University of Hawai’i
University Health Services Mānoa
1710 East West Road, Honolulu, Hawai’i 96822
Phone 808-956-8965 Fax 808-956-3583
Secure email via File Drop: www.hawaii.edu/filedrop
Recipient: UHSM
HEALTH INSURANCE
If you do not have health insurance, we highly recommend that all students obtain coverage. Health
insurance is mandatory for international students and students enrolled in specific programs.
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The University Health Service can bill many non-HMO insurance companies for services provided at UHSM.
(There are some exceptions, and we do not bill Med-QUEST, listed below.) Although you do not need to
have insurance to use the on-campus health services, you will be asked to provide insurance coverage
information when you visit. To expedite the clinic registration process, please return the completed
Insurance Information Form and a front and back copy of your medical insurance card to:
University Health Services Mānoa
1710 East West Rd.
Honolulu, HI 96822
At the Health Service, charges for uninsured students are reasonable; however, costs for off-campus care,
emergencies, and hospitalization can be extremely high. We highly recommend that you obtain insurance
to cover these situations.
HOW TO OBTAIN HEALTH INSURANCE COVERAGE
1) Students who have coverage through their parents’ employee health plans:
Under the Affordable Care Act (www.healthcare.gov), young adults will be allowed to stay on their parents' plan
until they turn 26 years old (some exceptions may apply). Contact your insurance provider for specifics.
2) Students who wish to purchase their own health insurance coverage:
University of Hawai‘i endorsed student health insurance plans are available for regular registered students. The
current plans are provided by Hawaii Medical Services Association (HMSA). The coverage terms and premiums are
very favorable. Please see our website for details. Application forms are available at the University Health Services
or can be downloaded from the HMSA website at www.hmsa.com/portal/student.
3) Students who may qualify for the State of Hawai‘i Med-QUEST plan:
Med QUEST is a State health insurance plan for those who meet low-income criteria. For more information,
please visit the Department of Human Services, Med QUEST website: http://humanservices.hawaii.gov/mqd/
4)
Out-of state students and students who have non- Hawai‘i or foreign insurance plans:
Please review carefully the terms of your health insurance coverage. Your insurance may not cover medical
services performed away from your home location and/or designated medical facilities or providers.
IMPORTANT for International Students: The University requires that all international students maintain adequate
medical health insurance and medical evacuation and repatriation coverage while attending UH. For F-1
students, go to
http://www.hawaii.edu/shs
for more information. For all other international
students, go to the
office that handles your visa for more information.
Please feel free to visit the University Health Services at 1710 East West Road. We will be happy to answer
any questions you may have concerning your health care needs on campus. Telephone 808-956-
8965. You may also visit our web site at http://www.hawaii.edu/shs. For questions on the UH Student
Plan, you may also contact the Student Health Insurance Office at shio@hawaii.edu
.
University of Hawai’i
University Health Services Mānoa
1710 East-West Road | Honolulu, Hawai’i 96822
Phone (808) 956-8965 FAX (808) 956-3583
Secure email via File Drop:
www.hawaii.edu/filedrop Recipient: UHSM
HEALTH
INSURANCE INFORM
ATION
SHEET
PATIENT INFORMATION
Name: Last First Middle
UH ID #
Preferred First Name (if applicable)
Date of Birth (MM/DD/YY)
Sex
Gender
Local Address City State Zip code
Phone
( )
Permanent Address City State Zip code
Phone
( )
Employer
Employer Address
Phone
( )
Emergency Contact
Relationship
Phone (Home)
( )
Phone (Work/Cell)
( )
PRIMARY INSURANCE Company: Please attach copy of card (front and back)
Name of Insurance
Policy
or ID#
Group #
Subscriber Subscriber Date of Birth
Subscriber Sex Plan #
Subscriber Address City State Zip code
Name of Primary Care Provider
Phone
( )
Effective
Date
Expiration
Date
Relationship to Subscriber: self child spouse other, specify: ______________________
For HMSA subscribers only. Choose UHSM to be your primary care provider: Yes No
SECONDARY INSURANCE Company: Please attach copy of card (front and back)
Name of Insurance
Policy
or ID#
Group #
Subscriber Subscriber Date of Birth
Subscriber Sex Plan #
Subscriber Address City State Zip
Effective
Date
Expiration
Date
Relationship to Subscriber: self child spouse other, specify: ______________________
INSURANCE CARRIER: I hereby authorize release of information necessary to file a claim with my insurance company and ASSIGN
BENEFITS OTHERWISE PAYABLE TO ME, TO THE UNIVERSITY OF HAWAI’I AT MĀNOA, UNIVERSITY HEALTH SERVICES
AS INDICATED ON THE CLAIM.
I understand I am financially responsible for any balance not covered by my insurance carrier.
Signature of Patient (Parental signature required if under 18) Date
APPOINTMENT REMINDERS VIA TEXT:
I consent to receive text message reminders from UNIVERSITY HEALTH SERVICES MĀNOA at the phone number provided,
including my wireless number. I understand that I may be charged for such messages by my wireless carrier and that such messages
may be generated by an automated messaging system, and that I may opt-out of this service at any time.
Signature of Patient (Parental signature required if under 18) Mobile Number Mobile Carrier Date
Revised 2/24/2020
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DOH TB Control Program
DOH TB Clearance Manual
7/18/2017
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?
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DOH TB Control Program
DOH TB Clearance Manual
7/18/2017
High-incidence countries include any country with an annual TB rate over 20/100,000. Source: http://www.who.int/tb/country/data/download/en/Revised Oct 2016.
TB Document J: State of Hawaii List of High Risk Countries
Hawaii State Department of Health Tuberculosis Control Program
Africa
Algeria
Côte d'Ivoire Liberia Senegal
Angola Dem. Rep. of the Congo Madagascar Seychelles
Benin
Equatorial Guinea
Malawi Sierra Leone
Botswana Eritrea Mali South Africa
Burkina Faso
Ethiopia
Mauritania Swaziland
Burundi Gabon Mauritius Togo
Cameroon Gambia
Mozambique
Uganda
Cape Verde Ghana Namibia United Rep. of Tanzania
Central African Rep. Guinea
Niger
Zambia
Chad Guinea-Bissau Nigeria Zimbabwe
Comoros
Kenya
Rwanda
Congo
Lesotho
Sao Tome and Principe
Eastern Mediterranean
Afghanistan
Kuwait
Qatar
Tunisia
Djibouti
Libyan
Somalia
Yemen
Iran Morocco
South Sudan
Iraq
Pakistan
Sudan
Europe
Armenia Georgia
Poland The Former Yugoslav
Azerbaijan Greenland Portugal Turkey
Belarus
Kazakhstan Republic of Moldova
Turkmenistan
Bosnia - Herzegovina Kyrgyzstan Romania Ukraine
Bulgaria Latvia
Russian Federation Uzbekistan
Estonia Lithuania Tajikistan
South-East Asia
Bangladesh India Myanmar
Thailand
Bhutan Indonesia
Nepal
Timor-Leste
Dem. People's Rep. of Korea Maldives
Sri Lanka
The Americas
Anguilla
Dominican Republic
Honduras
Saint Vincent - Grenadines
Argentina
Ecuador
Mexico
Suriname
Belize
El Salvador
Nicaragua
Trinidad and Tobago
Bolivia
Guatemala
Panama
Turks and Caicos Islands
Brazil
Guyana
Paraguay
Uruguay
Colombia
Haiti
Peru
Venezuela
Western Pacific
Brunei Darussalam
Japan
Nauru
Republic of Korea
Cambodia
Kiribati
New Caledonia
Singapore
China
Lao People's Dem. Rep.
Niue Solomon Islands
China, Hong Kong SAR
Malaysia
Northern Mariana Islands
Tuvalu
China, Macao SAR
Marshall Islands
Palau
Vanuatu
Fiji
Micronesia (Fed. States of)
Papua New Guinea
Viet Nam
French Polynesia
Mongolia
Philippines
Wallis and Futuna Islands
Guam
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Completed 9 December 2020

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