Annual Health Appraisal Form Page 2
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2Name: ____________________________
Student Identification #: __________________
(7 Digit People Soft ID)
(Please Print)
TUBERCULOSIS SCREENING (2 STEP PPD TEST)
(Mantoux required. The second PPD Test must be administered between 1 week to 3 weeks after the first PPD Test. These tests CANNOT be completed during a single visit with a physician.)
_____ /_____ /_______
DATE READ TEST 1
RESULTS?
Negative / Positive
(circle one)
(Month / Day / Year)
_____ /_____ /_______
DATE READ TEST 2
RESULTS?
Negative / Positive
(circle one)
(Month / Day / Year)
CHEST X-RAY
(Required if tuberculin skin test is Positive)
_____ /_____ /________
X-RAY DATE
RESULTS?
Normal / Abnormal
(circle one)
(Month / Day / Year)
Comments
:
_________________________________________________________________________
(Required if tuberculin skin test is Positive)
_______________________________________________________________________________________________________________________________________________
PART III: EXAM EVALUATION AND VERIFICATION
(HEALTH CARE PROVIDER TO COMPLETE)
I have obtained a health history, performed a physical examination and reviewed the student’s immunization status and required laboratory
tests. In my opinion this student is able to fully participate in clinical education in the School of Health and Rehabilitation Sciences:
Yes / No
(circle one)
If this student is NOT fully able to participate,
please comment on activity limitations here:
__________________________________________________________________________________________
( Statement of Limitations)
________________________________________________________________________________________________________________________________________________
*** IMPORTANT NOTICE ***
The YEAR on the Provider date below must correspond with the upcoming calendar year that is going to
be covered by the data on this form.
________________________________________________________________________________________________________________________________________________
PROVIDER INFORMATION
Name
CRNP / MD / DO / PA
(circle one)
(Please Print)
Signature
______________________________
Date
______ / _____ / _________
(Month / Day / Year)
Phone Number:
(______)__________________
________________________________________________________________________________________________________________________________________________
NOTE:
ALL SECTIONS ON THIS FORM MUST BE COMPLETED BEFORE ITS
SUBMITTAL
FORM SUBMITTAL
(Upon Completion)
This form should be returned BY THE STUDENT to:
University of Pittsburgh
Wellness Center
Nordenberg Hall
119 University Place
Pittsburgh, PA 15260
Form Version: September 16, 2013
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