Incoming / New Students – Health Clearance documents.

Physical Examination – Can be used for physicals that may be required by a clinical rotation site.

TB Symptoms Health Screening Checklist – If you require a chest x-ray for TB clearance OR if you obtained IGRA (e.g. Quantiferon or T-spot) test, you must complete this form on a yearly basis.

New PPD Skin Test Converters – Provides information on what you need to do in order to obtain TB clearance if your previous tuberculosis skin tests were negative but your most recent is now positive.

Authorization to Email – Consent form you must complete, sign, and date then submit to the SEHO in order for them to email your health documents to your WesternU email.

Blood Borne Pathogen Labs – Laboratory tests you need to obtain if you had any exposure to blood, or body fluids (i.e. needle stick).

COVID-19 Related Documents

Travel History – Report planned and recent travel history.

COVID-19 Clinical Exposure Procedure

COVID-19 Symptom Procedure for Campus, Rotations, and Home

COVID-19 Symptoms/Exposure Reporting – Due to the recent increased prevalence of Coronavirus, aka COVID-19, we are requesting that any member of the WesternU Community complete the following questionnaire. Student-Employee Health needs to know if you or another member of WesternU has been exposed to someone with a confirmed case of COVID-19 or appears to be exhibiting signs and symptoms associated with this virus.

COVID-19 Vaccination Medical/Disability Exemption Form

COVID-19 Vaccination Religious Exception Form

COVID-19 Vaccination Pregnancy Deferral Form

QR Code for Daily Self-Screening App

 

All students, faculty, employees, and visitors must complete the WesternU COVID-19 Self-Screening survey on the day of and prior to their on-campus visit. This QR code has been created for ease of access to the Qualtrics Survey. If you do not have a QR code reader on your phone, please visit https://covid.westernu.edu/.

 

Activity Questionnaire

  • Please use this form to request to have any on-campus activity. WesternU off-campus activities will not require approval from the CRT. The CRT will use this form to evaluate the activity’s planned procedures and make recommendations on any protocols that need to be improved upon or followed before the activity may be held. Please e-mail completed forms 2 weeks in advance of the activity to: CRT@westernu.edu for approval. The CRT requires activity organizers to keep a list of all event attendees for both on-campus and off-campus activities. In the event of an outbreak, attendee lists will be requested for contact tracing purposes.