The Health Clearance Form document is a total of seven pages, however you only need to fill out and submit the second, third, and fourth pages labeled “Health Clearance Form” and “Mandatory Health Requirements (Parts 1 & 2)”.
Contains detailed information about immunization and tuberculosis (TB) testing. Please read carefully.
Labeled “Health Clearance Form”. You must return this page of the form. Please fill it out as completely as possible.
Labeled “Mandatory Health Requirements (Part 1 & 2)”. You must return this page of the form. Please fill it out as completely as possible.
- Part I (“Tuberculosis Control”) requires you to have a tuberculin (TB) skin test conducted by by a U.S.-licensed health care provider, as required by Hawai’i State law. Because it can be quite difficult to locate a U.S.-licensed health care provider outside of the U.S., most exchange/visiting students complete Part I of the Health Clearance Form when they first arrive in Hawai’i and report to the University Health Services clinic for a tuberculin (TB) skin test. The test takes a minimum of 48-72 hours to complete and the cost for the test is $12 USD (subject to change). University Health Services provides the tuberculin (TB) skin test every weekday except Thursday. Check the University Health Services website for opening hours and further details.
- Part II (“MMR”) requests that you provide evidence of your MMR (measles, mumps, rubella) immunization record. Part II of the form does NOT need to be completed by a U.S.-licensed physician and can be completed by doing one of the following:
- A) have your health care provider complete and sign Part II; or,
- B) submit a copy of your school or public health immunization record; or,
- C) submit a copy of a health care provider’s record.
- University Health Services will review your Health Clearance Form and inform you if any additional medical information may be required to receive final clearance.
Fourth / Fifth Pages
The “Health Insurance” information on the fourth page is primarily intended for U.S. citizens; unless you are a U.S. citizen, you do not need to complete or submit the “Health Insurance Information Sheet” on the fifth page.
Please do not email the Health Clearance Form to MIX; it must be submitted directly to University Health Services by postal mail, fax, or UH File Drop. University Health Services does not accept the form by email.
Exchange and visiting students coming to Hawai’i from abroad may submit their Health Clearance form after the deadline stated on the form. However, students who do not submit the Health Clearance form before the first day of instruction will be automatically un-enrolled from all of their previously registered classes.
Exchange and visiting students who plan to live in on-campus housing must obtain a complete Health Clearance (MMR immunization AND TB clearance) before they will be permitted to move in to their housing.