Annual Health Appraisal Form printable pdf download

Name: ____________________________

Student Identification #: __________________

(7 Digit People Soft ID)

(Please Print)

UNIVERSITY OF PITTSBURGH SCHOOL OF HEALTH AND REHABILITATION SCIENCES

ANNUAL HEALTH APPRAISAL FORM

Please print unless otherwise indicated. All Date Fields required by this Form must be legible and completed with Month,

Day and Year Values. Failure to comply with these requests will prevent your registration for the upcoming Term and

prevent your participation in Clinical Education.

*** THIS BOX FOR SHS OFFICIAL USE ONLY ***

STUDENT LEVEL

Junior / Senior / Post Bac. / Graduate / Other

After Data Entry Complete, Initial Here:

(Circle One for Upcoming Term)

PART I: STUDENT INFORMATION

(ALL AREAS MUST BE COMPLETED)

STUDENT IDENTIFICATION NUMBER

(7 Digit People Soft ID - NOT Campus ID card Number; NOT Personal SSN)

NAME

(Last Name)

(First Name)

(Middle)

ADDRESS

(Street)

(City/State/Zip Code)

TELEPHONE _(______)___________________________

(MUST BE COMPLETED BY STUDENT)

HEALTH INSURANCE

I verify that I carry, and will carry for the entire duration of my program, health insurance that will cover payment of treatment

and follow-up procedures related to bloodborne pathogens, other potentially infectious materials, and any illness or injury that

could occur during class or clinical.

______________________________

Date

______ / _____ / _________

(Student Signature)

(Month / Day / Year)

PART II: LABORATORY/DIAGNOSTIC TEST INFORMATION

(HEALTH CARE PROVIDER TO COMPLETE)

Comment required if positive. Results MUST be reviewed by health care provider and attached to this form. Forms

returned with only results attached will be considered incomplete.

_________________________________________________________________________________________________________________________________________________________________________

HEPATITIS B

(The administering of this vaccine series CANNOT be completed during a single visit with a physician.)

_____ /_____ /________

VACCINE DOSE 1

DOSE 2

DOSE 3

(Month / Day / Year)

_____ /_____ /________

TITER DATE

RESULTS?

Immune / Non-Immune

(circle one)

(Month / Day / Year)

□

Check here when you are attaching a signed refusal form if immunization is contraindicated

(Refusal form is available in Student Health Service Office)

Form Version: September 16, 2013

Annual Health Appraisal Form

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