Community Heath Screening Approval Form


  • Health Screening Approval Form

    This form is required for all health screening events involving WesternU students. The process ensures that WesternU students are covered by the University’s medical malpractice insurance. After completing the form contact Office of University Student Affairs (USA) or COMP-Northwest Student Affairs to receive approval and the compliance paperwork. • Submit this form no less than FOUR weeks before your scheduled event. • Return the required documentation no more than ONE week following the event.



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    WesternU Organizers

  • e.g. samplestudent@westernu.edu; sallystudent@westernu.edu



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    Event Information

  • Example: Interprofessional Health Fair, October 11, 2025
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • :
  • :






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    Attendee Information

  • Check all that apply.
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    Faculty/Preceptor Information

  • The University has approved the screenings found on the Scope of Practice Guide linked below. This guide will tell you what clinicians are required to oversee the activity and which students are allowed to participate. Sope of Practice Guide
  • Must be a WesternU Faculty member or Preceptor and licensed in the State of California or Oregon.



  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • This is needed to verify affiliation with university if not a faculty member. If WesternU faculty, type WesternU.
  • Check all that apply.






  • Please include the necessary information in the block below.
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    Vaccines



  • Vaccines You indicated you are providing vaccines as a services. Please let us know the following:

  • E.g. San Bernardino County, LA County, WesternU Pharmacy, etc.
  • Clinician must have a California Immunization Registry (CAIR) login.
  • List names of PharmD students assisting with vaccines. If you don't know your student volunteers names yet leave blank and e-mail to studentaffairs@westernu.edu along with their APhA certificates.
  • PharmD students assisting with vaccines must provide proof of their APhA certificate before participating. You may upload their certificates here (merge all into one .pdf) or e-mail them to studentaffairs@westernu.edu
    Max. file size: 125 MB.


  • Contract

  • Certificate of Liability Insurance (COI)*: If the Community Organizer (CO) is asking for a COI, ask them to contact University Student Affairs (studentaffairs@westernu.edu) directly. Contract/Agreement*: All contracts must be reviewed by University Legal and signed by a designated signatory. If the CO requires a contract, please send it to: studentaffairs@westernu.edu. *COI requests may delay approval by 2 weeks and a contract by 4-6 weeks.
  • If yes, it must be reviewed by our legal department and signed by a designated signatory.
  • Only .pdf files accepted.
    Accepted file types: pdf, Max. file size: 125 MB.
  • Please provide any other information about the event that we may need to know.