Trinitas School of Nursing Health Clearance Information

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1 Trinitas School of Nursing Health Clearance Information Students are required to have health clearance before they are allowed to register for NURE 131 and higher courses. All NURE 132, NURE 231, NURE 232, and continuing LPN to RN students: Mantoux test (TB) must be done annually. To be allowed to register for your course, your TB test should cover the year till December 15, Submit the result to P. Stansfield. You must have your name and the NURE course on this report. If you had a past positive TB test, you do not have to do the TB test nor do you need to repeat your chest x-ray. If you received a MMR (Measles, Mumps, Rubella) vaccine in the Fall 2009 semester, you must repeat the blood titer for the disease that you were not immune to. This will show whether you have built immunity to the vaccine that you received. Submit this titer or titers to P. Stansfield as soon as you receive the result. Drug screening by Trinitas Occupational Health Department should have been done once unless specified by school administration. Evidence of Flu vaccine or signed waiver form. All NURE 130 students who plan to register for NURE 131. Download all pages of the health form from the school website, Click on Nursing Program Forms, then Student Health Packet. Be sure that your name, address, student ID number and phone number are legible on the form. The physical exam form must be completed by your doctor or health care provider. Ask your doctor or your health care provider to review all lab results with you including: MMR (Measles, Mumps, Rubella) titer, Varicella (chicken pox) titer, and Hepatitis B. If you are not immune to these diseases, you must take the vaccine accordingly. Follow-up titers would be done three months after the administration of the vaccine. Test for Hepatitis B. If you are not immune to Hepatitis B, you may sign the Hepatitis B waiver form (in your health packet) if you do not wish to have the vaccine. Mantoux test (TB) must be done annually. To be allowed to register for NURE 131, your TB test should be good till December 15, Submit the result to P. Stansfield. You must have your name and the NURE course on this report. If you had a past positive TB test, you do not have to do the TB test nor do you need to repeat your chest x-ray. Drug screening at Trinitas Hospital Occupational Health Department, 1 st floor Administrative Services Bldg., Trinitas Hospital, 225 Williamson St., Elizabeth, NJ. Call for appointment ( ). The student is responsible for the fee of $ Complete the form at the end of this packet and take with you for the drug screening. Evidence of Flu vaccine or signed waiver form. Note to all: Make a copy of all your health forms for your records. Submit all original forms to Patricia Stansfield, RN, Health Coordinator, by May 20, In her absence, you may submit your packet to the School of Nursing Office in Room 324. Mrs. Stansfield s office hours are on Tuesdays, from 4-10 PM in Room 337. Her phone number is Her address is

2 STUDENT HEALTH RECORD Please complete this form to the best of your ability and bring it to your Physician, Nurse Practitioner, Physician Assistant for your physical examination. Make a copy of your completed Health Record and submit the copy to our Health Nurse, Mrs. Stansfield, or the School Administrative office Room 324. RETURN TO: Mrs. Patricia Stansfield Trinitas School of Nursing 40 West Jersey Street Elizabeth, New Jersey

3 STUDENT HEALTH RECORD Name (Last) (First) Middle Initial Fall Semester Spring Semester CWID# Course: NURE Section: Day Evening Weekend Birth Date Male Female Address City State Zip Code Home Phone# Cell # Work # STUDENT: Please check all items that apply to you: Allergies Asthma Arthritis or Rheumatism Back Injuries Chest pains Chronic back pain Convulsions Diabetes Dizzy spells or fainting Hearing problems High blood pressure Migraine or severe headaches Hepatitis Bronchitis or Chronic cough Psychiatric disorder Heart disease Tuberculosis Surgery Epilepsy Any other serious illness State details for all items check above: List present medications: I certify that to my knowledge I have had no injury, illness or ailment other than specified and permit the examining Health Care Provider to submit a medical report including test results to Trinitas School of Nursing. Signature Date

4 STUDENT HEALTH RECORD TO BE COMPLETED BY PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISANT Weight Height Pulse Resp. B/P General Appearance Skin Hair PHYSICAL FINDINGS Eyes Visual Acuity: Without Correction, Right Left With Correction, Right Left Ears Hearing Acuity: Right Left Nose Mouth Throat/Neck Respiratory Cardiovascular Breasts/Axilla Abdomen/Hernia Genitalia Musculoskeletal Neurological Psychological Endocrine Lymph Nodes Hematological Flu Vaccine Date: Waiver form attached and signed: Mantoux Date: Results: mm Interpretation ( ) Negative ( ) Positive If Positive: Date Chest X-Ray Chest X-Ray Result Treatment I have examined (student) and found no indication of any disease or condition which might affect the health and safety of the student or the health and safety of the clients whom the student may provide care to. This student is able to fully participate in the clinical rotation. Signature: (Health Care Provider) Date: Name (PLEASE PRINT) Address City State Phone # Fax MD/NP/PA STAMP:

5 WAIVER FOR FLU VACCINATION I am requesting that Trinitas School of Nursing waive the health requirements for the FLU VACCINATION and I have signed this declination below. Signature Date

6 STUDENT HEALTH RECORD TO BE COMPLETED BY HEALTH CARE PROVIDER A COPY OF THE ACTUAL LABORATORY TITER RESULT MUST BE SUBMITTED WITH THIS FORM Rubeola Titer { } Immune { } Non-Immune: Vaccine required Date Given Mumps Titer { } Immune { } Non-Immune: Vaccine required Date Given Rubella Titer { } Immune { } Non-Immune: Vaccine required Date Given Varicella Titer { } Immune { } Non-Immune: Vaccine required Date Given HBsAb Titer { } Negative: If Negative Vaccination Recommended or Declination signed { } Positive HBsAg Titer { } Negative { } Positive: If Positive MD Counseled and Cleared Date If Hepatitis B Vaccine Series is/has been given list: Date # 1 Date #2 Date #3 Signature (Health Care Provider) Date Hepatitis B Virus Vaccine Declination Due to personal, medical or religious reasons, I am requesting that TRINITAS SCHOOL OF NURSING Waive the health requirement for immunization against Hepatitis B. I am aware of the health risks of this disease, the mode of transmission, and possibility of exposure to Hepatitis B to health care professionals. Student Signature Date

7 MR#: EMPLOYEE HEALTH DEPT. REGISTRATION FORM Fax : Phone: SCHOOL OF NURSING NAME : SOCIAL SECURITY # DATE OF BIRTH: ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: CELL PHONE: drug screnn consent and reg. 10/09

8 Drug Testing: Preparations: Please Take: Trinitas Occupational Medicine/ Emp. Health210 Williamson Street (1 st Floor) Elizabeth, NJ Administrative Building Directions for Drug Screen Phone: Call to schedule appointment Drug Screening Hours: Mon Fri (07:30am 2:00pm) The test is performed by urinalysis. Please drink plenty of fluids prior to your appointment. You will need to remain at the collection facility until you are able to void a sufficient volume for the sample. The Fee is $60.00 (cash Only) Please this form, bring a photo ID, such as your driver s license, or school ID. Please know that you will no be allowed to carry anything into the collection room with you, such as bags coats, purses, briefcases, etc. Also, refrain from wearing baggy clothing that could be used to conceal adulterants or other means of subverting the accuracy of the test. DRUG SCREENING TEST CONSENT Trinitas Hospital and Trinitas School of Nursing maintains a drug free environment. Therefore, as part of a pre-clinical physical examination to insure I am physically able to perform the clinical component of my program, I am required to provide a urine sample for testing to determine my status for illegal drug use. Students with a positive drug screen and/or an adulterated drug screen for illegal drugs will not be allowed into or remain in the nursing program of Trinitas School of Nursing. I,, consent to providing a sample of my urine to be tested for drug content. If I refuse to sign the consent or provide a sample for drug screening, I understand that the health clearance will not be completed satisfactorily and I will not be allowed in the clinical course at this time. I understand that I will be informed of the results of these tests and that appropriate action will be taken, consistent with the policy of Trinitas School of Nursing. I understand that a positive illegal drug screen and/or an adulterated drug screen will be reported to the Dean of Trinitas School of Nursing for appropriate action, consistent with the policy of Trinitas School of Nursing. Student Signature: DOB: Date: Did you have anything to eat today? ( ) Yes ( ) No Please list any and all medications currently being taken:

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