Student Health Clearance Certificate Form PDF Details

As a student attending college, it is important to make sure you are healthy and up-to-date on all of your immunizations. To do this, most schools require students to obtain a Student Health Clearance Certificate form. This document will collect essential information about your health history, physical examination results, immunization records, and other medical details necessary for enrollment in the school. In this post we'll discuss why these forms are so important and how they can help ensure that everyone stays safe while at college. We'll also cover what's typically included in the forms so you know what information to have ready when applying for your own certificate of clearance!

QuestionAnswer
Form NameStudent Health Clearance Certificate Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstudent health certificate form, health certificate form for students pdf download, medical certificate for students, medical form for college 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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