Health Clearance Form
Once you have been officially accepted as an inbound exchange student to UHM, you must complete the Health Clearance Form.
NOTE: It is OK to submit the form after the stated deadline, but you must submit it before course registration begins.
The form must be sent to University Health Services Manoa by mail, fax, or UH File Drop. University Health Services does NOT accept this form by email. Please do NOT email your form to MIX; it must be submitted directly to University Health Services.
The Health Clearance Form is five pages long, but you only need to submit two pages. The first page contains useful information. The two pages that you need to return to University Health Services Manoa are pages 2 and 3. These are the “Health Clearance Form” and the “Immunization Record,” and are actually numbered “1 of 2” and “2 of 2."
You may disregard part I ("Tuberculosis Control"). When you arrive to UHM, you will be required to report to University Health Services for a tuberculin (TB) skin test.
- You must complete Part II ("MMR") and provide your MMR (measles, mumps, rubella) immunization record. You can either A) have your health care provider complete this page of the Health Clearance Form, B) submit a copy of your school or public health immunization record, or C) submit a copy of a health care provider's record.
- The "Health Insurance" information on page 4 is primarily intended for U.S. citizens; unless you are a U.S. citizen, you do not need to complete the "Health Insurance Information Sheet" on page 5.
Health Insurance for International Students
Both J-1 and F-1 visa holders must provide proof of health insurance in the U.S. that meets certain minimum coverage requirements in order to receive "health insurance clearance". NOTE: You are a J-1 student if you received a DS-2019 form; you are an F-1 student if you received an I-20 form.
J-1 students - You will receive your health insurance clearance from the International Student Services Office (ISS). For an overview of health insurance in the U.S. and to see the four options that you have for receiving health insurance clearance, please read the J-1 Health Insurance FAQ Sheet. At your Visa Clearance Session, you must submit proof of health insurance to ISS to receive your health insurance clearance. Questions? Contact ISS at firstname.lastname@example.org.
F-1 students - You will receive your health insurance clearance from the Student Health Insurance Office (SHIO). For an overview of health insurance in the U.S. and to see the three options that you have for receiving health insurance clearance, please read the F-1 Health Insurance FAQ Sheet. Upon arrival to UHM, you must submit proof of health insurance to SHIO in Queen Liliuo'kalani Center (QLC) for Student Services Room 313-D to receive your health insurance clearance. Questions? Contact SHIO at email@example.com.