Form Deh-001 - Health Certificate Clearance Application Page 2
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3HEALTHCARE PROVIDER CERTIFICATION
NOTE TO ALL HEALTHCARE PROVIDERS: Please review the following instructions before completing this form.
PPD TEST RESULTS: Report the result of PPD skin test by giving the date the PPD was given, the date read, and the
measurement in millimeters (mm).
Section A:
This section is to be completed only if the applicant is free of communicable diseases, including those for
which screening is specified.
Section B:
This section is to be completed only if the applicant is not free of communicable diseases, including those for
which screening is specifically indicated. Applicants with positive PPD skin tests must be referred by their
physician to their reference x-ray facility to have a routine chest x-ray performed to screen for active
tuberculosis. This x-ray must be read and interpreted by a licensed radiologist and a written report prepared
for the physician.
COMMUNICABLE DISEASE CONTROL (CDC) CERTIFICATION: CDC certification is to be signed ONLY by the
CDC Tuberculosis Program Coordinator of the department upon completion of all the reporting requirements and after the
CDC physician’s medical evaluation certifies that the applicant has completed/or is currently under treatment and has been
.
certified as non-contagious
WARNING: THIS CLEARANCE IS NOT VALID UNLESS THE PRINTED NAME AND SIGNATURE OF THE
PHYSICIAN/AUTHORIZED PERSON (INCLUDING TITLE) ARE PRESENT IN SECTION “A” OR “B” ALONG
WITH THE PHYSICIAN’S/AUTHORIZED PERSON’S STAMP AND THE REQUIRED MEDICAL INFORMATION.
: Date Given: _________________, Date Read: ________________, Reading: ___________ (mm)
PPD TEST RESULT
PLEASE CHECK AND COMPLETE EITHER SECTION “A” OR “B” AS APPROPRIATE
I have performed the health screen tests indicated on the front of this form and find the applicant:
A
B
□
□
is free of the communicable diseases for which
is NOT free of the communicable diseases for which
screening is indicated above for the occupation in
screening is indicated above for the occupation in
which the applicant desires employment.
which the applicant desires employment.
____________________________________________
Attached are the copies of the following indicated
Physician’s or other Authorized Name (Print or Stamp)
documents:
□ Physical Examination (Health Screen) Form
____________________________________________
□ A written report of laboratory test results.
If not Physician, Title (Print or Stamp)
□ A copy of the official Radiological Report.
□ Other (Specify) ____________________________
____________________________________________
Signature
Date
____________________________________________
This Applicant should go directly to the DIVISION OF
Physician’s or Other AUTHORIZED Name
(Print or Stamp)
ENVIRONMENTAL HEALTH at the Department of
Public Health and Social Services in Mangilao to continue
___________________________________________
processing.
If not Physician, Title
(Print or Stamp)
____________________________________________
COMMUNICABLE DISEASE CONTROL
____________________________________________
CERTIFICATION
Signature
Date
FOR COLUMN “B” TO THE RIGHT:
This Applicant should go directly to the COMMUNICABLE
□
□
The applicant
may
may not
DISEASE CONTROL PROGRAM, ROOM 118, at the Dept. of
Be employed in the occupation indicated above as of this
Public Health and Social Services in Mangilao to continue
Processing.
Date: __________________________
___________________________________________
FOR DEH USE ONLY:
________________________________________
Received by: _______________________________
Signature: DPH&SS, CDC Certifying Officer
Date: _____________________________________
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