“SA ; Ss PEDIATRIC MEDICAL GROUP, LLC + A712 LIUHA STREET, SUITE 304 HONOLULU, HAWAII 96817 ‘TELEPHONE: 522-1313 FAX: 522-1309 4 VON if ‘TO WHOM IT MAY CONCERN: THIS is TO cerTiFY THAT___\_ove\, HAD MMR VACCINES ON _={| |S SIYPERELY, IEUAR. M.D. LEOVIGILDO RAMIREZJR.,Daw v.16 (DRECTOR OF HEALTH STATE OF HAWAII DEPARTMENT OF HEALTH P..0, 80x 3378 HONOLULU, HI 86801-9378 February 23, 2018 FINULIAR, LOVELY PINKY F 636 IHE STREET HONOLULU, HI 96817 Dear LOVELY PINKY FINULIAR, This is your certificate of the tuberculosis (TB) examination which attests that you are free of communicable TB at this time. This certificate fulfils TB clearance requirements per Hawaii Administrative Rules Title 11, Chapter 164, Department of Health, August 2001. Should you have any questions, please contact one of the following Hawaii Tuberculosis Control Branch locations. Hawaii-East: (808) 974-6025 Hawaii-West: (808) 322-1500 Kauai: (808) 241-3387 Maui: (808) 984-8260 Molokai: (808) 553-7880 Lanai: (608) 565-7114 Oahu: (808) 832-5731 Dp Certified this day by: Cn Elizabeth M. MacNeill, MD-MPH Chief, Tuberculosis Control Branch TB Test Result(s) Chest Radiograph Date: 02-21-2018 Result: Negative STATE OF HAWAII DEPARTMENT OF HEALTH ‘Tuberculosis Clearance Certificate ‘The TB clearance provides @ reasonable assurance that the individual listed on this form is currently free from infectious tuberculosis at the time of the exam. This form does not imply any {guarantee or protection from future tuberculosis risk for the individual listed, FINULIAR, LOVELY PINKY F DOB: 07-04-1999 ‘TB Clearance Date: 02-21-2018