Student Health Clearance Certificate Form PDF Details

The Student Health Clearance Certificate is a comprehensive form designed to ensure students' fitness and immunity status before they embark on their educational journey, especially in sensitive environments like medical schools. This document gathers crucial health information, including personal details, vaccination records, and specific test results such as those for Tuberculosis (TB) and Human Immunodeficiency Virus (HIV). It mandates the submission of test results for TB within a year and HIV within six months, underscoring the institution's commitment to maintaining a healthy campus. Additionally, it requires proof of immunity against a wide array of diseases, from Hepatitis B and C to Mumps, Measles, Rubella, and more through documented vaccine dates and titer counts. The form goes further by inquiring about the student’s physical fitness, any chronic health problems, and a self-declaration of being free from addiction, which signifies the comprehensive measures taken by the American University of the Caribbean School of Medicine to ensure both student and community health are prioritized. Students are also reminded of the obligatory health insurance coverage, emphasizing the institution's thorough approach in safeguarding well-being and compliance with St. Maarten government regulations for student residency permits. Completing and submitting this form, duly filled and signed by a healthcare provider, along with the student's declaration and verification by an official, becomes a critical step in the admission process, highlighting the importance of transparency, accountability, and health-consciousness in the academic setting.

QuestionAnswer
Form NameStudent Health Clearance Certificate Form
Form Length2 pages
Fillable?Yes
Fillable fields68
Avg. time to fill out14 min 10 sec
Other namesmedical certificate for student, student health certificate form, medical certificate form pdf for students, health certificate for students

Form Preview Example

Student Health

Clearance Certificate

Name

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

Phone

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Semester:

0 Winter 20

 

0 Summer 20

0 Fall 20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All Test Results must be attached with this form.

I. Tuberculin Skin Test:

(Mandatory within one year except those with positive skin test history.)

Type of Test:

 

Date Tested:

 

Date Read:

 

 

 

 

 

 

0 Positive

0 Negative

 

 

For those with a history of positive tuberculin test, the following is mandatory:

Date of last chest X-ray:

Radiologist X-ray report: 0 Positive

0 Negative

II. HIV Test:

(Mandatory within six months)

Date Tested:

0 Positive

0 Negative

(Positive results will not necessarily bar a person from staying in St. Maarten, but will require liaison with the local health authorities.)

III. Mandatory Proof of Immunity

Hepatitis B:

1st Date:

 

/

 

/

2nd Date:

/

/

 

3rd Date:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis C: Blood Screen Date:

 

 

 

 

 

Titer Count:

 

 

 

 

 

 

 

Measles:

Vaccine Date:

 

 

 

 

 

 

 

 

Titer Count:

 

 

 

 

 

 

 

American University of the Caribbean School of Medicine • 901 Ponce de Leon Blvd, Suite 700, Coral Gables, Florida 33134 • Fax 305.444.6791 • Toll Free 866.DR2B.AUC

www.aucmed.edu

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10168D10_11

Mumps:

Vaccine Date:

 

Titer Count:

Rubella:

Vaccine Date:

 

Titer Count:

Varicella:

Vaccine Date:

 

Titer Count:

Poliomyelitis:

Vaccine Date:

 

Titer Count:

Diphtheria:

Vaccine Date:

 

Titer Count:

Pertussis:

Vaccine Date:

 

Titer Count:

Tetanus:

Vaccine Date:

 

Titer Count:

Influenza:

Vaccine Date:

 

Titer Count:

IV. Signatures

To be filled out by a health provider:

1. Does this student have any acute/chronic health problems? If yes explain.

2. Date of last physical exam:

/

/

 

 

 

 

 

 

 

 

 

Results of the exam:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s printed Name:

 

 

 

 

 

 

 

 

 

Licence #

 

 

 

Office Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

Country:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

 

 

 

 

Email:

 

 

 

 

I verify that the information is true.

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Physician:

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

Statement of Self Declaration of Fitness

 

 

 

 

 

 

 

 

 

 

 

 

I,

 

 

 

 

 

 

 

 

, state that I am physically fit and free of habituation or addiction to depressants,

stimulants, narcotics, alcohol, and/or other drugs or substances which may alter my behavior of effect my judgment. Any false information,

omission, or misrepresentation will constitute grounds for dismissal from the University.

Signature of Student:

 

Date

 

 

Verified by AUC Official:

 

 

Date

 

 

Note: All AUC students are required to have adequate global health insurance coverage. All Medical Sciences students must enroll in the AUC sponsored student health insurance policy underwritten by National General Insurance Corporation, NV (NAGICO). This is a requirement to receive a student residency permit from the government of St. Maarten.

Please return Student Health Clearance Certificate to: American University of the Caribbean School of Medicine

901 Ponce de Leon Blvd., Suite 700, Coral Gables, Florida 33134

American University of the Caribbean School of Medicine • 901 Ponce de Leon Blvd, Suite 700, Coral Gables, Florida 33134 • Fax 305.444.6791 • Toll Free 866.DR2B.AUC

 

www.aucmed.edu

2

10168D10_11

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