UCEAP Health Clearance Form - UC Education Abroad Program

UCEAP Health Clearance Form
STUDENT INSTRUCTIONS
Refer to your UC Campus EAP Office health instructions as well. The UCEAP health clearance is a mandatory requirement for
participation; it cannot be waived. All information is confidential and only shared with staff who will assist with facilitating health care,
particularly during an emergency, while you are an EAP student.
1. Do not delay in making your health clearance appointment. Comply with the health clearance DEADLINE: no later than 60 days
before departure (except for Chile). Students who are not in compliance may not be approved to participate in, or may be
dismissed from, EAP.
2. Complete the Confidential Health History form (if your campus has online clearance procedures, follow them). Write your name,
UC campus, and UCEAP program name, on the attached form before your appointment.
3. Inform the UCEAP Systemwide Office (UCEAP) of medical needs, accommodations, and/or changes in health that occur after the
health clearance process. Failure to provide complete and accurate information may be grounds for non-participation in,
or dismissal from, EAP.
4. Return the original and a copy of this form by the stipulated deadline to: Systemwide Office of UCEAP, University of California, 6950
Hollister Avenue, Suite 200, Goleta, CA 93117-5823.
HEALTH CARE PROVIDER INSTRUCTIONS— READ car ef ully bef or e s igni ng f orm—
Health provider must be licensed in the U.S. and cannot be an immediate family member (AMA Code of Ethics E-8.19)
• The student must complete required information on the attached form. Blank forms, without the student’s name, are not acceptable.
• Consider the student’s fitness and physical and mental health in relation to the country, the type of program, and the
conditions in which the applicant will be living. University of California will not approve a student’s participation in EAP unless you
certify that the student is medically stable.
HEALTH CARE PROVIDER FOLLOW THESE STEPS:
1. The student must present to you a completed UCEAP Confidential Health History form. Please review the form for
accuracy. A physical examination is not needed unless required by the program, or UC Student Health Center.
2. Discuss/review the student’s health history thoroughly referring to the Confidential Health History form completed by
the student and the student’s medical records on file, paying particular attention to medications and immunizations that the
student may need, any allergies the student may have, and all currently active health problems.
3. Pay special attention to any physical, emotional or psychological conditions. UCEAP is concerned for the well-being of
students with a history of health conditions that require medication and/or continued therapy while abroad.
a. Students may be cleared for participation if
i. in the opinion of the examining practitioner and/or specialist, any medical condition they may have is under control,
ii. they have a contracted treatment plan in place (if there is any evidence of recent health/mental health treatment), for
required and recommended care while abroad, and
iii.
they have been stable on their medication for a reasonable period.
4. Student is advised to find out if the medication is locally available or if there is an appropriate substitute. If not locally available,
student is advised to carry a sufficient supply to last through UCEAP, but only if the medication can legally be brought into the
country.
5. List any physical, emotional, or learning disabilities the student may have so UCEAP can help the student to determine the
availability of adequate local services.
If a specialist/s is/are currently seeing the student for an ongoing condition, each specialist must also approve and sign this clearance
form, and provide legible contact information or the form may be returned. Please note that the student must be cleared to participate in
UCEAP by a physician/health practitioner and each specialist.
University of California UCEAP Health Clearance Form
STUDENT: Print clearly with a ball point pen before appointment
First and Last Name of Student
UC Campus
EAP Program Name (Country/Host University/Term)
HEALTH PROVIDER: Forms without signatures and required information will be considered incomplete and will be returned
Review student’s Confidential Health History form and medical records on file. Discuss the student’s health history thoroughly in relation to the country, type of
program, and local resources. If student is seeing a specialist, the approval and signature of the specialist(s) must be obtained before final clearance is granted.
I have reviewed the student’s Confidential Health History form, and medical records on file, with the student. Based on the information provided to me by the
student on the Confidential Health History form, and following a review of the student’s personal health history, to the best of my knowledge, the student is:
Licensed Psychotherapist/Licensed Specialist* (Section and signature required if checked)
1.
CLEARED (Check all that apply below)
1.a No medical or psychiatric contraindications to EAP participation.
1.b Student advised to arrange services to facilitate education (e.g., note-taking, wheelchair access). A letter from the UC Disability Services
Office documenting disability and indicating who will pay for services is required.
1.c. Student advised to arrange services to facilitate a healthy and safe stay abroad (e.g., regularly available psychiatric therapy, etc.).
Indicate that student has treatment plan in place and is stable.
1.d Student advised to find out if the medication is locally available or if there is an appropriate substitute. If not locally available, student advised
to carry a sufficient supply to last through EAP, but only if the medication can legally be brought into the country. If on medication, please list.
2.
3.
Student is NOT CLEARED: There are medical contraindications to EAP participation.
Student is NOT CLEARED: There are psychiatric contraindications to EAP participation.
Licensed Specialist/Psychotherapist (PRINT LEGIBLY name and title):
__________________________________________________________________________________
Phone number (include area code):
Signature:__________________________________________________________________________
Date:
Licensed Physician/Health Practitioner*
1.
CLEARED (Check all that apply below)
1.a No medical or psychiatric contraindications to EAP participation.
1.b Student advised to arrange services to facilitate education (e.g., note-taking, wheelchair access). A letter from the UC Disability Services
Office documenting disability and indicating who will pay for services is required.
1.c. Student advised to arrange services to facilitate a healthy and safe stay abroad (e.g., regularly available psychiatric therapy, etc.). Indicate
that student has treatment plan in place and is stable.
1.d Student advised to find out if the medication is locally available or if there is an appropriate substitute. If not locally available, student
advised to carry a sufficient supply to last through EAP, but only if the medication can legally be brought into the country. If on medication,
please list. Indicate if significant allergy to any medication.
2.
Student is NOT CLEARED: There are medical or psychiatric contraindications to EAP participation.
Licensed Physician/Health Practitioner, MD, NP, DO, PA, or RN, (PRINT LEGIBLY name and title):
__________________________________________________________________________________
Phone number (include area code):
________________________________
Signature: __________________________________________________________________________
Date: ____________________________
*Health provider must be licensed in the U.S. & cannot be an immediate family member (AMA Code of Ethics E-8.19)
Upon completion, the student must send copies of this form to UCEAP by the
deadline. UCEAP will mail one copy to the UCEAP Study Center.
PHYSICIAN RUBBER STAMP OR BUSINESS CARD HERE
One copy: Health care provider – Original & 1 copy: UCEAP Universitywide Office, 6950 Hollister Avenue, Suite 200, Goleta, CA 93117-5823