Get University Of Hawaii LCC Health Immunization Clearance Form 2020-2024

455. 0515 Fax 808. 455. 0267 www. hawaii. edu/shs/lcc HEALTH CLEARANCE FORM Instructions 1. Please complete the sections below and return this form to the Health Center AD-122. FALL 20 SPRING 20 SUMMER 20 University of Hawai i - Leeward Community College Student Health Center 96-045 Ala Ike Pearl City HI 96782-3393 Phone 808. Please note that registration will not be allowed until all health clearances are met. 2. These health clearances must be completed by a U*S* licensed MD DO APRN PA or clinic* Name UH ID Last First Middle Mailing Address City State Zip code Email Address Daytime Phone Birthdate / / TUBERCULOSIS CLEARANCE REQUIREMENTS TB clearance must be dated within one year of the first day of the semester and clearly state that the skin test or chest x-ray was negative. Transfer or returning students who are/were enrolled at a Hawai i college may bring a copy of the original clearance certificate used to first attend a post-secondary school in Hawai i. For Physician s/Clinic Use Only TB PPD-MANTOUX Date given Date read Results in mm OR CHEST X-RAY required if skin test is positive 10mm or Date x-ray taken X-ray results Printed Name of Physician/Clinic Telephone No* Official Signature Date MEASLES MUMPS RUBELLA MMR CLEARANCE REQUIREMENTS A student born before 1957 is exempt from the Measles Mumps and Rubella immunization requirement Proof of TWO doses of the Measles Rubeola vaccine at least ONE must be the Measles Mumps Rubella MMR vaccine with the first dose on or after 12 months of age and second dose at least 4 weeks after the first dose OR Positive Measles Mumps Rubella MMR lgG blood test report copy of blood test report required COMPLETE ONE OF THE FOLLOWING 1. Proof of two MMR immunizations Date 1 mo day year 2. Measles Rubeola vaccine 1 / 2 / Mumps vaccine 1 / Rubella vaccine 2 or Physician documentation of disease date 3. Antibody titers Measles Date titer results Mumps Date titer results Rubella Date titer results Signature Date OFFICE USE ONLY TB MMR SOAHOLD GOAMEDI By/Date. Please note that registration will not be allowed until all health clearances are met. 2. These health clearances must be completed by a U*S* licensed MD DO APRN PA or clinic* Name UH ID Last First Middle Mailing Address City State Zip code Email Address Daytime Phone Birthdate / / TUBERCULOSIS CLEARANCE REQUIREMENTS TB clearance must be dated within one year of the first day of the semester and clearly state that the skin test or chest x-ray was negative. Transfer or returning students who are/were enrolled at a Hawai i college may bring a copy of the original clearance certificate used to first attend a post-secondary school in Hawai i. Transfer or returning students who are/were enrolled at a Hawai i college may bring a copy of the original clearance certificate used to first attend a post-secondary school in Hawai i. For Physician s/Clinic Use Only TB PPD-MANTOUX Date given Date read Results in mm OR CHEST X-RAY required if skin test is positive 10mm or Date x-ray taken X-ray results Printed Name of Physician/Clinic Telephone No* Official Signature Date MEASLES MUMPS RUBELLA MMR CLEARANCE REQUIREMENTS A student born before 1957 is exempt from the Measles Mumps and Rubella immunization requirement Proof of TWO doses of the Measles Rubeola vaccine at least ONE must be the Measles Mumps Rubella MMR vaccine with the first dose on or after 12 months of age and second dose at least 4 weeks after the first dose OR Positive Measles Mumps Rubella MMR lgG blood test report copy of blood test report required COMPLETE ONE OF THE FOLLOWING 1.