1 of 7 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.

• Students with history of a positive PPD skin test and negative chest x-ray must complete and returnthe Tuberculosis Symptom Screening form. This form can be found on our website:http://www.hawaii.edu/shs, under Forms and Memos.

2) IMMUNIZATION CLEARANCE (REQUIRED)• 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 afterage 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 studentsliving in on-campus housing who are age 16 through 20. You will not be allowed to check into youron-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

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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:

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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' planuntil 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. Thecurrent plans are provided by Hawaii Medical Services Association (HMSA). The coverage terms and premiums arevery favorable. Please see our website for details. Application forms are available at the University Health Servicesor 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 medicalservices 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 adequatemedical health insurance and medical evacuation and repatriation coverage while attending UH. For F-1students, go to http://www.hawaii.edu/shs for more information. For all other international students, go to theoffice 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 INFORMATION SHEET

PATIENT INFORMATIONName: Last First Middle UH ID #

Preferred First Name (if applicable) Date of Birth (MM/DD/YY) Sex

Gender

UH Email Address

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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