Form Deh-001 - Health Certificate Clearance Application
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3GOVERNMENT OF GUAM
DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES
Division of Environmental Health, Health Certificate Program
Division of Public Health, Communicable Disease Control Program
HEALTH CERTIFICATE CLEARANCE APPLICATION
PLEASE COMPLETE BOX BELOW BEFORE PRESENTING THIS FORM TO YOUR HEALTHCARE PROVIDER
Applicant’s Name: ____________________________________________________________ Citizenship: _______________
Last
First
Middle
□
□
Birth Date: ______/______/_______
Social Security # _______- _______ - ________
Sex:
Male
Female
(Mo.)
(Day)
(Year)
Contact Number: (Work) ______________________ (Home) _______________________ (Cell) ______________________
Mailing Address: __________________________________________________________________________________________
Residential Address: _______________________________________________________________________________________
Place of Employment: __________________________________________________ Location: _________________________
Job Title: _______________________________________________________ Ethnicity/Nationality: ____________________
I certify that the information provided above is true and accurate to the best of my knowledge:
SIGNATURE: _________________________________________________
Date: ____________________________
NOTE TO APPLICANT: A valid photo (i.e.; passport, driver’s license, authorization to work for alien workers, or other valid photo I.D.) must be presented
when submitting this form to the department..
TYPE OF APPLICATION
NOTE TO HEALTHCARE PRACTITIONER: The above named person is applying for DPH&SS Health Certificate
in the occupation category checked below.
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NEW APPLICANT
RENEWAL APPLICANT
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COSMETOLOGY:
EATING & DRINKING/FOOD ESTABLISHMENT:
● PPD skin test for TB – if positive, perform chest x-ray
● PPD skin test for TB – if positive, perform chest x-ray
● Certification of Examination
□
COSMETOLOGY:
● Professional License
● PPD skin test for TB – if positive, perform chest x-ray
□
MASSAGE: (Two photographs required)
● Certification of Examination
● PPD skin test for TB – if positive, perform chest x-ray
● Professional License
● Certification of Examination
□
MASSAGE: (Two photographs required)
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TATTOO:
● PPD skin test for TB – if positive, perform chest x-ray
● PPD skin test for TB – if positive, perform chest x-ray
● Certification of Examination
● Certification of Examination
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TATTOO:
□
INSTITUTIONAL (Nursing Home, Adult Care,
● PPD skin test for TB – if positive, perform chest x-ray
Child Care, Correctional Facility):
● Certification of Examination
● PPD skin test for TB – if positive, perform chest x-ray
□
INSTITUTIONAL (Nursing Home, Adult Care,
● Physician’s Certification of Examination
Child Care, Correctional Facility):
□
LAUNDRY/DRY CLEANING:
● PPD skin test for TB – if positive, perform chest x-ray
● PPD skin test for TB – if positive, perform chest x-ray
● Physician’s Certification of Examination
● Physician’s Certification of Examination
□
LAUNDRY/DRY CLEANING:
□
THERAPEUTIC MASSAGE: (Two photographs required)
● PPD skin test for TB – if positive, perform chest x-ray
● PPD skin test for TB – if positive, perform chest x-ray
● Physician’s Certification of Examination
● Certification of Examination
□
THERAPEUTIC MASSAGE: (Two photographs required)
● Professional License
● PPD skin test for TB – if positive, perform chest x-ray
● Certification of Examination
● Professional License
HEALTHCARE PROVIDER CERTIFICATION ON REVERSE SIDE →
DEH-001 (Rev. 10/6/10)
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