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To be completed by a physician or other health care provider after reviewing the student’s health history, and when relevant, after obtaining specialist approval for serious ongoing conditions. The form records the examining provider’s determinations that the student is able to participate in planned travel, along with signatures, printed names, dates, and—if applicable—specialist details and address, and includes Banner ID.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/xavier-university-risk-management-insurance-health-screening-examination-form/429838/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/xavier-university-risk-management-insurance-health-screening-examination-form/429838.png","ImageObject",300,407,{"name":92,"@type":93},"Theodore","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-09-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Who is required to complete this health screening examination form?","Question",{"text":112,"@type":113},"A physician or other health care provider should complete it after reviewing the student’s Health History Form.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"When is specialist approval required?",{"text":117,"@type":113},"For students seeing a specialist for a serious ongoing condition, approval from the specialist must also be obtained.",{"name":119,"@type":110,"acceptedAnswer":120},"What information does the form include for confirming travel readiness?",{"text":121,"@type":113},"It includes the provider’s determination that the student can participate in the planned travel experience, along with physician signature, printed name, date, and—if applicable—specialist signature, printed name, specialty, and address.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},429838,1790741427,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81},7971461740886,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","XAVIER UNIVERSITY – RISK MANAGEMENT & INSURANCE Rev. 7/1/2017  \nHHF 202 Health Screening Examination Form (for Student Studying or Traveling Abroad)  \nHEALTH SCREENING EXAMINATION  \n(To be performed by a physician or other health care provider)  \nA physician or other health care provider should complete this form after reviewing the student’s Health History Form with the student. For students seeing a specialist for a serious ongoing condition, the approval of the specialist must also be obtained.  \nI have completed a history and physical examination of   , a student at Xavier University. Based on my examination and based on their current mental and physical health, I have determined that they are able to participate in the planned travel Experience in    \n.  \nPhysician’s Signature Date  \nPhysician’s Printed Name  \n* * * * * * * *  \nSpecialist’s Signature (if applicable) Date  \nSpecialist’s Printed Name and Specialty  \n_________________________________________________  \n_________________________________________________  \nSpecialist’s Address  \nBanner ID:    \nThis is the only form approved by Xavier University for this purpose. It may not be modified or changed in any way.","cbCailrd1gDDSz6j","https://ap.wps.com/l/cbCailrd1gDDSz6j","pdf",26762,"English","# Health Screening Examination Form\n## Completion requirements\n## Provider determination and signatures\n## Specialist section (if applicable)\n## Address and Banner ID","[{\"question\":\"Who is required to complete this health screening examination form?\",\"answer\":\"A physician or other health care provider should complete it after reviewing the student’s Health History Form.\"},{\"question\":\"When is specialist approval required?\",\"answer\":\"For students seeing a specialist for a serious ongoing condition, approval from the specialist must also be obtained.\"},{\"question\":\"What information does the form include for confirming travel readiness?\",\"answer\":\"It includes the provider’s determination that the student can participate in the planned travel experience, along with physician signature, printed name, date, and—if applicable—specialist signature, printed name, specialty, and address.\"}]","XAVIER UNIVERSITY - RISK MANAGEMENT & INSURANCE - Health Screening Examination Form | PDF",1790651318]