A. Required Every Year (every 12 months based on the date tests are performed): FORM A-1 & A-2

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1 Office of Clinical Affairs NYUCN Master s Program STUDENT HEALTH CLEARANCE (HC) POLICY & REQUIREMENTS POLICY: All students participating in clinical learning experiences at the NYU College of Nursing (NYUCN) must be in compliance with health clearance policies as required by New York University and the NYUCN. The student is responsible for providing NYU with evidence of immunity and health status. Students requesting a reasonable accommodation must register with the Moses Center, located at 726 Broadway, 2nd floor. Students are also required to make two copies of the original Health Clearance documents and: 1. Keep a copy of the Health Clearance (HC) documents during tenure at NYUCN 2. Scan and , fax, hand deliver, or mail a copy of the completed and signed HC documents to: Office of Clinical Affairs NYU College of Nursing Fax: Phone: nursing.healthclearance@nyu.edu PURPOSE OF POLICY: NYUCN students have clinical learning experiences and are placed in direct contact with patients. This contact places students at risk for both exposure to and transmission of communicable diseases and blood-borne pathogens. Therefore, specific procedures are needed to (1) decrease health risks to students, (2) protect patients and other health care professionals with whom students interact, and (3) comply with NYUCN healthcare agency contracts, New York University Student Health Center policies, OSHA regulations, and New York State Department of Health policies. Note: Health clearance is required for any course that includes a clinical experience. Health clearance must be met no later than six (6) weeks prior to the first day of the clinical course or participation will be prohibited. HEALTH CLEARANCE REQUIREMENTS: Carefully review the requirements below to successfully complete the attached Health Clearance Packet in its entirety. Please note that the NYUCN Health Clearance Requirements are different from the NYU Student Health Center requirements. Information on the NYU Student Health Center is available at The NYU Student Health Center s Meningococcal Meningitis response form is also attached at the end of this packet. A. Required Every Year (every 12 months based on the date tests are performed): FORM A-1 & A-2 1. History & Physical (H&P): Students must have a History and Physical performed yearly by a health care provider (physician or nurse practitioner). The date of the H&P must be indicated on FORM A Two-Step PPD (Mantoux) or QuantiFERON-TB Gold (blood test): Students must have a Two-Step PPD (second PPD is administered 1 to 3 weeks after first PPD) OR documentation of annual TB tests within the previous two years. OR QuantiFERON-TB Gold test performed yearly. The date the PPD test was administered & the date the test was determined negative or positive must be indicated on FORM A-2. If a QuantiFERON-TB test is performed, the laboratory report and test results must be submitted. A positive PPD or QuantiFERON-TB test requires a one-time only post-positive chest x-ray report. An abnormal chest x-ray requires documentation of medication regimen and yearly documentation of a TB symptom check. Page 1 of 12

2 Office of Clinical Affairs B. Required One Time Only: FORM B 1. Measles, Mumps, and Rubella All students must demonstrate immunity to Measles, Mumps and Rubella with proof of positive IgG titers (a laboratory blood test for the antibodies) against Measles, Mumps, and Rubella. Evidence of immunity is demonstrated with the titer value and indication of + or immune on FORM B. Negative or Equivocal MMR Titers require the student to receive one (1) MMR booster vaccine & provide proof of childhood vaccination history. All students must submit copies of laboratory reports with titer results. 2. Varicella All students must demonstrate immunity to Varicella (Chicken Pox) with proof of positive IgG titers (a laboratory blood test for the antibodies) against Varicella. Evidence of immunity is demonstrated with the titer value and indication of + or immune on FORM B. Negative or Equivocal Varicella Titer requires the student to receive two (2) doses of Varicella vaccine spaced four (4) weeks apart. All students must submit copies of laboratory reports with titer results. 3. Tetanus /Diptheria/Pertussis Vaccine (Tdap) All students must present evidence of the date of vaccination for Tetanus/Diphtheria/Pertussis (Tdap) within the last 10 years. If no documentation is presented, the student must receive a Tdap vaccine. 4. Hepatitis B (HBV) Proof of vaccination against Hepatitis B inclusive of titer as proof of immunity to Hepatitis B (indication of HBsAb titer value as Immune or Positive (+)); or documentation on FORM D that the student has either commenced or declined the Hepatitis B vaccine series. Non-immune titer results require the student to receive three (3) doses of Hepatitis B vaccine spaced over a six (6) month period, and document the commencement of the vaccine on FORM D. If a student decides to decline the Hepatitis B vaccination, the student must sign FORM D documenting that he/she understands the possible risks associated with acquiring Hepatitis B. C. Required Every Flu Season: FORM C 1. Flu Vaccine: As per the New York State Department of Health, the flu vaccine is required during flu season (September through May). All students must complete FORM C in its entirety. D. CPR/Basic Life Support Certification for Healthcare Providers: Students are required to submit a copy of CPR/BLS Certification for Healthcare Providers from the American Heart Association. Programs requiring additional credentialing are included on the next page. E. Technical Standards: Students must read and sign the last page of the attached Technical Standards. Page 2 of 12

3 Office of Clinical Affairs In Case of an Injury, Hospitalization and/or Absence to due to Medical Condition: 1. Students who miss a clinical for hospitalization or for any health impairment, physical condition, or mental illness that renders the individual contagious and/or incapable of safely performing nursing student clinical responsibilities must submit health clearance authorization from an appropriate healthcare provider prior to returning to the clinical area to complete a rotation. Health Clearance is submitted to the NYUCN Office of Clinical Affairs using the Interim Health Clearance Form. 2. In order for students to provide safe patient care as well as protect themselves and other students from any potential injury, they may not attend on-campus clinical simulation or off-campus clinical learning sessions if they must use a cane, cast, walking boot, crutches, and/or other assistive/restrictive devices for an acute short-term musculoskeletal injury. 3. After a student is cleared by the NYUCN Office of Clinical Affairs, the student must contact the Program Coordinator to review the NYUCN MS Program s on-campus and/or off-campus clinical make-up policy. Additional Credentialing Requirements: 1. NOTE: certain health care agencies/clinical sites may require additional documentation and/or training (i.e. background check, state child abuse registry certification, HIPAA training, drug testing). If additional documentation is required, the Office of Clinical Affairs will contact students on an individual basis. 2. Before the start of each semester, all MS Students must complete a Practicum Application Form (included in this packet) and submit it with their current resume & New York State RN License Registration to their respective Master s Program. An out-of-state RN License Registration must also be submitted for clinical placements not in New York. (See requirements listed below for each respective program.) (NRAC) APN: Adult Acute Care ACLS (NRPC) APN: Adult Primary Care Page 3 of 12

4 Office of Clinical Affairs Adult Primary Care Specialty Sequences: Holistic Nursing Palliative Care Nursing (NRFNP) APN: Family APN: Geriatrics (NRMG) Joint Degree MS Nursing/MS Management (NRMH) APN: Mental Health Mental Health Specialty Sequence: Substance Related Disorders Page 4 of 12

5 Office of Clinical Affairs (NRNM) Midwifery *ACNM Membership *'NRP (Neonatal Resuscitation Program) *IV Certification (Course or Letter from Supervisor) *Electronic Fetal Monitoring skills (NRAD) Nursing Administration (NRIF) Nursing Informatics (NRED) Nursing Education (NICA) APN: Pediatrics *PALS Page 5 of 12

6 Office of Clinical Affairs MS CLINICAL COURSES REQUIRING HEALTH CLEARANCE: Master s Program NURSE-GN.2012 NURSE-GN.2017 NURSE-GN.2019 NURSE-GN.2023 NURSE-GN.2168 NURSE-GN.2030 NURSE-GN.2032 NURSE-GN.2037 NURSE-GN.2062 NURSE-GN.2063 NURSE-GN.2065 NURSE-GN.2069 NURSE-GN.2097 NURSE-GN.2098 NURSE-GN.2099 NURSE-GN.2117 NURSE-GN.2119 NURSE-GN.2130 NURSE-GN.2132 NURSE-GN.2134 NURSE-GN.2135 NURSE-GN.2133 NURSE-GN.2136 NURSE-GN.2137 NURSE-GN.2138 NURSE-GN.2140 NURSE-GN.2142 NURSE-GN.2173 NURSE-GN.2175 NURSE-GN.2177 NURSE-GN.2187 NURSE-GN.2188 NURSE-GN.2179 NURSE-GN.2180 NURSE-GN.2181 NURSE-GN.2183 NURSE-GN.2185 NURSE-GN.2186 NURSE-GN.2232 NURSE-GN.2233 NURSE-GN.2234 NURSE-GN.2235 NURSE-GN.2143 NURSE-GN.2144 NURSE-GN.2145 Clinical Course Advanced Physical Assessment Across the Lifespan Adult-Gerontology Primary Care: Practicum II Adult-Gerontology Primary Care: Practicum III Nursing Administration Practicum: II Nursing Administration Practicum: III Geriatric Syndromes Health Promotion for Infancy, Childhood & Adolescence Common Health Problems of Adults and Older Adults & Seminar Pediatric Primary Care: Practicum I Pediatric Primary Care: Practicum II Pediatric Primary Care: Practicum III Substance Abusing Client Practicum II Intro to Palliative Care Symptom Mgt in Palliative Care Advanced Palliative Care Practicum Adult-Gerontology Acute Care: Practicum II Adult-Gerontology Acute Care: Practicum III Midwifery Mgmt: Practicum I Midwifery Mgmt: Practicum II Midwifery Mgmt: Practicum III Midwifery Mgmt: Practicum IV Primary Care of Women MH I: Individual Psychotherapy Across the Lifespan MH II: Foundations of Psychiatric APN Across the Lifespan MH III: Group, Couple and Family Psychotherapy Across the Lifespan MH IV: Child & Adolescent Psychiatric APN Practicum and Supervision MH V: Adult and Geriatric Psychiatric APN Practicum and Supervision Nursing Education: Practicum II Nursing Education: Practicum III Primary Care of the Older Adult with Multiple Chronic Conditions Clinical Intensive in Interprofessional Care of Older Adults Primary Care of the Frail Older Adult with Multiple Chronic Conditions Introduction to Primary Care Primary Care of Families: Child & Adolescent Health Primary Care of Families: Women s Health Primary Care of Families: Adult & Geriatric Health Practicum Primary Care of Families Across the Lifespan Practicum Nursing Strategies: Health Promotion Across the Lifespan Assessment and Analysis of Clinical & Nursing Information Systems Database Design and Decision Support on Clinical &Nursing Systems Implementation, Management and Evaluation of Clinical & Nursing Systems Nursing Informatics Integration Advanced Holistic Nursing: Foundations Advanced Holistic Nursing: Strategies for Health Coaching and Behavior Change Advanced Holistic Nursing: Healing with Complementary & Alternative Modalities Page 6 of 12

7 Office of Clinical Affairs Health Clearance Checklist Students are responsible for maintaining up-to-date Health Clearance (HC) documentation for the entire academic year. If HC information expires during the course of the academic year, students are responsible for submitting updated Health Clearance to the NYUCN Office of Clinical Affairs. Students are responsible for submitting all required paperwork to the NYU Health Center and NYUCN Office of Clinical Affairs at least 6 weeks prior to the start of clinical courses, and/or at the time student s HC information expires. Failure to submit the proper HC may result in a delay in starting clinical rotations or de-enrollment. A. FORM A-1 & Form A-2: Form A-1: Documented date of History & Physical (H&P) - Required Every Year (12 months) Form A-2 (required every 12 months): o 2 Step PPD (Mantoux) second PPD is administered 1 to 3 weeks after first PPD o OR documentation of annual TB tests within the previous two years. o OR QuantiFERON-TB Gold result with laboratory report attached required every year o If positive, copy of Chest X-Ray report attached (one-time only requirement) B. FORM B: Required One-time Only Measles, Mumps, and Rubella IgG titer values indicated by HC Provider, lab report attached Varicella Titer IgG titer values indicated by HC Provider, lab report attached Hepatitis B Proof of vaccination against Hepatitis B inclusive of titer result and laboratory report as proof of immunity to Hepatitis B (indication of HBsAb titer value as Immune or Positive (+)); or documentation on FORM D that the student has either commenced or declined the Hepatitis B vaccine series Tetanus/Diphtheria/Pertussis Vaccine (Tdap) exact date of vaccination within the last 10 years C. FORM C: Required during Flu Season (September through May) (may be obtained at NYU Student Health Center once the academic year begins) D. CPR/Basic Life Support Certification for Healthcare Providers from American Heart Association E. Technical Standards: Read Technical Standards, sign last page and submit with health clearance ** Practicum Application submitted with current resume and NYS RN License Registration to respective MS Program *** NYU Student Health Center Meningococcal Meningitis Vaccination Response Form completed and signed Health Clearance may be scanned and ed, faxed, hand delivered, or mailed to: Office of Clinical Affairs NYU College of Nursing Fax: Phone: nursing.healthclearance@nyu.edu **KEEP A COPY OF ALL DOCUMENTS FOR YOUR RECORDS** Page 7 of 12

8 Office of Clinical Affairs To be completed by student: FORM A-1 Annual History & Physical Examination Form Name (Print): Date of Birth: Phone #: (first, mi., last) NYU N Number: Current Clinical Course(s): (mm/dd/yyyy) Semester & Year: NXXXXXXXX I understand that the agency to which I am assigned may require more health data than listed below. I hereby authorize New York University to release my health clearance information on this form and all associated documents, including laboratory reports, drug tests, criminal background checks, and immunization waivers, to any health care provide/agency, which may require it in connection with my participation in a clinical course. I also understand that it is my responsibility to update FORM A annually. I agree that if I become ill, have a surgical procedure and/or become hospitalized, develop a condition, or have an exacerbation of a condition that limits my ability to fulfill the NYUCN Program requirements, I will obtain health clearance again from a health care provider before returning to the Program. I have brought the original of the required completed/signed HC documents to: 1) a copy to Office of Clinical Affairs, NYUCN,, & 2) kept an additional copy for my own records. Student Signature Date Program: BS MS DNP To be completed by a Certified Nurse Practitioner or Physician: An examination was performed on the above named individual. The following assessments were included: Complete history and physical (H&P) examination: Date of Exam: mm/dd/yyyy By signing below, the Health Care Provider (Nurse Practitioner or Physician) has determined that the named individual is eligible for clinical practice and agrees with the following statement: I find him/her to be in good physical and mental health; he/she is free from any health impairment which is of potential risk to patients, personnel, students, or faculty and which might interfere with the performance of his/her nursing student responsibilities, with or without a reasonable accommodation, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances that may alter the individual s behavior has been considered in this evaluation. If a reasonable accommodation is required, I have identified the accommodation and the basis of the accommodation on a separate attachment. NOTE: THIS FORM SHOULD NOT BE SIGNED UNLESS THE INDIVIDUAL IS ABLE TO PARTICIPATE FULLY IN NURSING PRACTICE. Date Signature of Nurse Practitioner or Physician Print or Type Name Address: Tel. No: Page 8 of 12

9 Office of Clinical Affairs To be completed by student: Program: BS FORM A-2 MS DNP Annual Tuberculosis Screening Form Name (Print): Date of Birth: Phone #: (first, mi., last) (mm/dd/yyyy) NYU N Number: NXXXXXXXX I understand that the agency to which I am assigned may require more health data than listed below. I hereby authorize New York University to release my health clearance information on this form and all associated documents, including laboratory reports, drug tests, criminal background checks, and immunization waivers, to any health care provide/agency, which may require it in connection with my participation in a clinical course. Student Signature Date mm/dd/yyyy To be completed by a Nurse Practitioner or Physician: An examination was performed on the above named individual. The following assessments were included: Two Step PPD: PPD #1 Date Administered: Date Read: Result: mm/dd/yyyy mm/dd/yyyy Second PPD is administered 1 to 3 weeks after the first PPD. OR, documentation of annual TB tests within the previous two years. The student must have a total of 2 PPDs within a 12 month period as of the date the student is beginning clinical. PPD #2 Date Administered: Date Read: Result: mm/dd/yyyy mm/dd/yyyy OR (one QuantiFERON-TB Gold test every 12 months) QuantiFERON-TB Gold Date Reported: Result: (lab report must be attached) mm/dd/yyyy PPD or QuantiFERON Positive Findings Positive Result: If positive, negative post positive chest x-ray report is required (a one-time only requirement as long as asymptomatic) Chest x-ray has been documented post-positive result? Copy must be attached Normal Chest x-ray mm/dd/yyyy Abnormal Chest x-ray Patient was/is treated with prophylactic medication. Date treatment started: / / Symptom Check for one (1) year post-positive PPD with annual H&P Signature of Nurse Practitioner or Physician Print or Type Name Current Clinical Course(s): Page 9 of 12 Semester & Year: Date: Address: Tel. No:

10 Current Clinical Course(s): Office of Clinical Affairs To be completed by student: FORM B Semester & Year: Program: BS MS DNP Name (Print): Date of Birth: Phone #: (first, mi., last) (mm/dd/yyyy) NYU N Number: NXXXXXXXX I understand that the agency to which I am assigned may require more health data than listed below. I hereby authorize New York University to release my health clearance information on this form and all associated documents, including laboratory reports, drug tests, criminal background checks, and immunization waivers, to any health care provide/agency, which may require it in connection with my participation in a clinical course. I also understand that it is my responsibility to update FORM A annually. I agree that if I become ill, have a surgical procedure and/or become hospitalized, develop a condition, or have an exacerbation of a condition that limits my ability to fulfill the NYUCN Program requirements, I will obtain health clearance again from a health care provider before returning to the Program. I have brought the original of the required completed/signed HC documents to: 1) a copy to Office of Clinical Affairs, NYUCN,, & 2) kept an additional copy for my own records. Student Signature Date Students Must Submit Titer Results & All Laboratory Reports Must be Attached Measles (Rubeola) Titer: Date Drawn IgG Titer Value Positive Negative Revaccination Date: (If Titer is Negative or Equivocal) Mumps Titer: Date Drawn IgG Titer Value Positive Revaccination Date: Negative (If Titer is Negative or Equivocal) Rubella Titer: Date Drawn IgG Titer Value Positive Revaccination Date: Negative (If Titer is Negative or Equivocal) Varicella Titer: Date Drawn IgG Titer Value Positive Revaccination #1 Date: Negative Revaccination #2 Date: *Past Titer Results are Acceptable. Titers do not need to be repeated. (If Titer is Negative or Equivocal) **Required: Vaccination History Must be Attached in the case of Negative Titers Hepatitis B: Dates of Vaccinations: # 1 # 2 # 3 AND (HBsAb) Titer: Date Drawn HBsAb Value Positive / Immmue OR Negative / Not Immune Signed Waiver of Declination: FORM D Tetanus/Diptheria/Pertussis Vaccine (Tdap) has been administered within ten (10) years Yes Date No Tdap administration is required. Date Administered Signature of Nurse Practitioner or Physician Print or Type Name Date Address: Page 10 of 12 Tel. No:

11 Office of Clinical Affairs 433 First Ave., 6 th Floor FORM C Seasonal Flu Vaccination Documentation Mandatory During Flu Season (September through May) Please complete all data requested below Name of Student or Faculty Member (first, mi., last) Date of Birth: (mm/dd/yyyy) Date of Vaccine Administration: (mm/dd/yyyy) Manufacturer: Lot: Dose: Product Name: Expiration Date: Injection Site: Person Administering (Name and Title): Signature of Person Administering: License #: Address: Completed Flu Vaccination Documentation may be scanned and ed, faxed, hand delivered, or mailed to: Office of Clinical Affairs NYU College of Nursing 433 First Ave., 6 th Floor Fax: Phone: nursing.healthclearance@nyu.edu Page 1 of 1

12 Current Clinical Course(s): Office of Clinical Affairs Semester & Year: Program: BS MS DNP FORM D Hepatitis B Vaccine Waiver (if vaccine is waived, submit one-time only) I understand that during my clinical learning experiences I may be exposed to blood or other potentially infectious materials, and I may be at risk of acquiring hepatitis B virus (HBV) infection, a serious disease. I have been given the opportunity to be vaccinated with hepatitis B vaccine. I am aware of the risks associated with acquiring Hepatitis B. Please check the appropriate statement: I decline hepatitis B vaccination at this time. I have been informed and understand the possible risks of acquiring hepatitis B. I am currently in the process of receiving the 3-dose series of hepatitis B vaccine at 0-, 1-, and 6-month intervals. I will obtain anti-hb serologic testing 1-2 months after dose #3. Until this process is completed, I have been informed and understand that I continue to be at risk of acquiring hepatitis B. Student Signature Print or Type Name NYU N Number Date: Adapted from Occupational Safety & Health Administration US. Department of Labor Standard Number: App A Can be waived; If a student has waived the Hepatitis B vaccination, the student indicates that he/she is aware of the risks of not receiving the Hepatitis B vaccination. Female students who believe they are pregnant must provide a letter from their health care provider indicating their expected delivery date and the lab result for Anti-Hepatitis B; although Hepatitis B vaccine is not contraindicated during pregnancy, the decision to receive the vaccination should be made in consultation with one s health care provider. Students are advised that some health care/clinical agencies will not allow anyone who has not received the Hepatitis B vaccination, and/or demonstrated immunity to Hepatitis B, to participate in a clinical rotation at their site. Page 12 of 12

13 New York University College of Nursing Master s Programs PRACTICUM APPLICATION FOR CLINICAL COURSES WITH A CLINICAL COMPONENT Course Name: Course No. Year: APN Adult Acute Care Nurse-Midwifery Nursing Informatics APN Adult Primary Care Substance Related Disorders Nursing Education APN Family Palliative Care Nursing Administration APN Mental Health Holistic Nursing Dual Degree MS Nsg/MS Mgt APN Pediatrics Geriatrics (post-masters) Dual MS/MPH (Global Public Health) Semester Fall Spring Summer Student Name: Address: City: State: Zip: Home Phone: Work Phone: Mobile # NYU Student ID # N Current Employer: Address: City: State: Zip: Position: Department: Title: Hours/Days: RN License (list all states): Emergency contact: Name: Phone: Relationship: Please discuss any special interests that may be pertinent to your clinical placement; (Including other languages spoken and if you have a car) I hereby authorize New York University and the College of Nursing to release all documents relevant to my placement in a clinical site to appropriate third parties, if necessary. This includes, but is not limited to, my health clearance, drug tests, criminal background checks, CPR certification, resume, license registration and this completed practicum application form Student Signature Date Print Signature Revised

14 New York State Department of Health Meningococcal Disease Last Reviewed: July 2011 What is meningococcal disease? Meningococcal disease is a severe bacterial infection of the bloodstream or meninges (a thin lining covering the brain and spinal cord) caused by the meningococcus germ. Who gets meningococcal disease? Anyone can get meningococcal disease, but it is more common in infants and children. For some adolescents, such as firstyear college students living in dormitories, there is an increased risk of meningococcal disease. Every year in the United States approximately 2,500 people are infected and 300 die from the disease. Other persons at increased risk include household contacts of a person known to have had this disease, immunocompromised people, and people traveling to parts of the world where meningococcal meningitis is prevalent. How is the meningococcus germ spread? The meningococcus germ is spread by direct close contact with nose or throat discharges of an infected person. What are the symptoms? High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal disease. The symptoms may appear two to 10 days after exposure, but usually within five days. Among people who develop meningococcal disease, 10 to 15 percent die, in spite of treatment with antibiotics. Of those who live, permanent brain damage, hearing loss, kidney failure, loss of arms or legs, or chronic nervous system problems can occur. What is the treatment for meningococcal disease? Antibiotics, such as penicillin G or ceftriaxone, can be used to treat people with meningococcal disease. Should people who have been in contact with a diagnosed case of meningococcal meningitis be treated? Only people who have been in close contact (household members, intimate contacts, health care personnel performing mouthto-mouth resuscitation, daycare center playmates, etc.) need to be considered for preventive treatment. Such people are usually advised to obtain a prescription for a special antibiotic (either rifampin, ciprofloxacin or ceftriaxone) from their physician. Casual contact, as might occur in a regular classroom, office or factory setting, is not usually significant enough to cause concern. Is there a vaccine to prevent meningococcal meningitis? There are three vaccines available for the prevention of meningitis. The preferred vaccine for people ages 2-55 years is Meningococcal conjugate vaccine (MCV4). This vaccine is licensed as Menactra (sanofi pasteur) and Menveo (Novartis). Meningococcal polysaccharide vaccine (MPSV4; Menomune [sanofi pasteur]), should be used for adults ages 56 and older. The vaccines are 85 to 100 percent effective in preventing the four kinds of meningococcus germ (types A, C, Y, W-135). These four types cause about 70 percent of the disease in the United States. Because the vaccines do not include type B, which accounts for about one-third of cases in adolescents, they do not prevent all cases of meningococcal disease. Is the vaccine safe? Are there adverse side effects to the vaccine? The three vaccines available to prevent meningococcal meningitis are safe and effective. However, the vaccines may cause mild and infrequent side effects, such as redness and pain at the injection site lasting up to two days. Who should get the meningococcal vaccine? The vaccine is routinely recommended for all adolescents ages years, all unvaccinated adolescents years, and persons years who are enrolling in college. The vaccine is also recommended for people ages 2 years and older who have had their spleen removed or have other chronic illnesses, as well as some laboratory workers and travelers to endemic areas of the world. Who needs a booster dose of meningococcal vaccine? CDC recommends that children age 11 or 12 years be routinely vaccinated with Menactra or Menveo and receive a booster dose at age 16 years. Adolescents who receive the first dose at age years should receive a one-time booster dose, preferably at ages years. Teens who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose, as long as they have no risk factors. All people who remain at highest risk for meningococcal infection should receive additional booster doses. If the person is age 56 years or older, they should receive Menomune. How do I get more information about meningococcal disease and vaccination? Contact your physician or your student health service. Additional information is also available on the websites of the New York State Department of Health, the Centers for Disease Control and Prevention, DiseasesConditions/; and the American College Health Association, Source:

15 Meningococcal Meningitis Vaccination Response Form This form is for new students, returning students, McGhee students, graduate students, and students over the age of 21 who do not live in a residence hall. (New students and returning students under the age of 21 must submit proof of meningitis vaccine.) RETURN FORM TO: NYU Student Health Center Immunization Record Services 726 Broadway, Suite 336 New York, NY Telephone: (212) Fax: (212) New York State Public Health Law 2167 requires that all college and university students enrolled for at least (6) semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete and return this form. Check ONE box and sign below: I have (for students under the age of 18, My child has... ) 1. had the meningococcal meningitis immunization (Menomune TM ) within the past 10 years. Date received: / / Doctor s signature: Stamp: 2. I am a newly admitted undergraduate student, attest to being over the age of 21, and DO NOT reside in an NYU residence. 3. I am a graduate student and have read or have had explained to me the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization against meningococcal meningitis disease. Signature: Date: / / Print Student s Name: Date of Birth: / / University I.D. Number: Student s Address: Student s Mailing Address: City: State: Zip: Student s Phone Number: ( ) - ( ) - NYUStudentHealthCenter Immunization Record Services 726 Broadway, Suite 336 New York, NY health.requirements@nyu.edu 9/7/11

16 THE NEW YORK UNIVERSITY COLLEGE OF NURSING TECHNICAL STANDARDS FOR CORE PROFESSIONAL NURSING COMPETENCY PERFORMANCE (DLT Approved: August 19, 2014) New York University College of Nursing ( NYUCN ) is committed to producing lifelong learners who will excel in their careers and be recognized as outstanding nurses who will be leaders in practice, research, policy, and education at the pre- and post-professional levels ( BS, MS, Post-MS Advanced Certificate, DNP, and PhD). The NYUCN Technical Standards for Core Professional Nursing Competency Performance ( Technical Standards ) are an integral component of NYUCN academic requirements that identify core professional nursing competencies in five specific domains Communication, Observation, Cognitive, Motor, and Behavioral and Social Attributes. Nursing students must meet all the requirements of the Technical Standards, with or without reasonable accommodations, in order to successfully progress through and graduate from their respective curricula. These requirements pertain to all student conduct regardless of setting (e.g. classroom/didactic, office, on-campus simulation or off-campus clinical, communication, etc.). Individuals interested in applying for admission to NYUCN are encouraged to review the Technical Standards to become familiar with the skills, abilities, and behavioral characteristics required to complete the programs as well as the related policy found at All NYUCN students must review the Technical Standards, sign the acknowledgment on the last page, and return this document to NYUCN Office of Clinical Affairs, 726 Broadway, 10 th Floor. Reasonable Accommodations for Qualified Individuals with Disabilities NYUCN is committed to providing educational opportunities to otherwise qualified students with disabilities to afford such students an opportunity equal to that provided to non-disabled students to achieve a desired educational outcome. A qualified individual with a disability is one who, with or without reasonable accommodations, meets NYUCN s academic requirements and Technical Standards. Students with disabilities are not required to disclose their disability to NYUCN. However, students wishing to request reasonable accommodations must register with NYU s Henry and Lucy Moses Center for Students with Disabilities (CSD) to initiate the process. Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act define a person with a disability as someone who: (1) has a physical or mental impairment that substantially limits one or more major life activities; OR (2) has a record of such an impairment; OR (3) is regarded as having such an impairment. Students are encouraged to meet with a CSD representative when unsure if a condition qualifies as a disability. CSD determines qualified disability status and assists students in obtaining appropriate accommodations and services. Decisions regarding reasonable accommodation are determined on a case by case basis taking into consideration each student s disability-related needs, disability Page 1 of 5

17 documentation and program requirements. While the process for requesting reasonable accommodations may be started at any time, reasonable accommodations may not be implemented retroactively. It therefore is important that students allow ample time for their accommodation requests to be processed. While NYUCN will make every effort to work with students with disabilities to accommodate their disability-related needs, NYUCN is not required to provide accommodations that fundamentally alter or waive essential program requirements. Students should review the information found on the CSD website ( or contact the CSD directly at: Henry and Lucy Moses Center for Students with Disabilities, 726 Broadway, 2nd Floor, New York, NY 10003, Phone: , Fax: , TECHNICAL STANDARDS COMPETENCY DOMAINS I. COMMUNICATION Competencies: The Technical Standards include the ability to communicate effectively with a wide variety of individuals. Rationale: communication competencies include knowledge, attitude, and skills necessary to provide quality and safe patient care in all health care settings. Examples of communication competencies include, without limitation, the ability to: communicate clearly in English, in a professional and sensitive manner, to patients or to a patient language interpreter ( if the patient and/or family members/significant others do not speak English), and their family members/significant others, health team members, faculty, and peers of diverse ethnic, religious, and cultural backgrounds in professional nursing practice settings as well as in the academic setting. elicit accurate information from patients, family member/significant others, health team members, and/or faculty related to a patient s medical history and current status necessary to adequately and effectively evaluate a patient s condition. use and comprehend standard professional nursing and medical terminology when using and/or documenting a patient s print or electronic health record. convey appropriate information to patients and the health care team and teach, direct and counsel a wide variety of individuals, including explaining treatment procedures and initiating health education. II. OBSERVATION Competencies: The Technical Standards include the ability to make observations in connection with other identified professional nursing student competencies. Rationale: Nursing student observation competencies include the knowledge, attitude, and skills necessary to provide quality and safe patient care to patients in all health care settings. Examples of observation competencies include, without limitation, the ability to accurately: use and interpret information obtained from digital, analog, and waveform diagnostic tools (e.g., sphygmomanometer, otoscope, stethoscope, ophthalmoscope, EKG, IVs) and other diagnostic tools that monitor or obtain physiological phenomena. Page 2 of 5

18 observe a patient during the course of a comprehensive or focused physical assessment to determine signs and symptoms of disease, pain, and infection. observe and interpret normal and deviations from normal the following: e.g., a patient s heart and body sounds, body language, color of wounds, drainage, urine, feces, expectoration, and sensitivity to heat, cold, pain, and pressure. III. COGNITIVE Competencies: The Technical Standards include the ability to demonstrate cognitive abilities in connection with the other identified professional nursing student competencies. Rationale: Nursing student cognitive competencies include demonstrating the knowledge, attitude, and skills necessary to provide quality and safe patient care to patients in all health care settings. Examples of cognitive competencies include, without limitation, the ability to: demonstrate cognitive abilities related to course and program outcomes, which include intellectual, conceptual, integrative, quantitative, critical thinking, and comprehension skills that indicate that the student is able to carry out the nursing process in the care of patients. measure, calculate, reason, analyze, and synthesize subjective and objective data to carry out the nursing process in relation to patient assessment, diagnosis, goals, plan of care/interventions, and evaluation. retrieve and critically appraise patient related research to determine the best available research evidence (quantity and quality) to use in a patient s nursing plan of care. comprehend extensive information from written documents, visual and/or oral presentations, and patient computer information systems in order to carry out the nursing process. analyze and prioritize all aspects of patient care in a prompt and timely fashion. synthesize objective and subjective findings and diagnostic studies in order to formulate nursing diagnoses. use synthesized data to initiate a nursing plan of care which appropriately integrates patient preferences in order to provide appropriate, quality, and safe patient care. accurately follow course syllabi, assignment directions, patient protocols, and any action plan(s) developed by deans, faculty, administrators, or health care agency staff. IV. MOTOR Competencies: The Technical Standards include the ability to perform or assist with nursing interventions to provide comprehensive general nursing care and treatment in connection with other identified professional nursing student competencies. Rationale: Nursing student motor competencies include the knowledge, attitude, and skills necessary to provide quality and safe patient care to patients in all health care settings. Examples motor competencies include, without limitation, the ability to: obtain accurate information from patients using gross and fine motor skills appropriate to the technique (e.g., palpation, auscultation, and percussion) and common medical/nursing digital, analog, and waveform diagnostic tools and equipment (e.g., sphygmomanometer, Page 3 of 5

19 otoscope, stethoscope, ophthalmoscope, EKG, IVs) that monitor or obtain physiological phenomena or data. perform and/or assist appropriately with expected nursing student procedures, treatments, and medication administration using sterile or clean techniques appropriate to the type of procedure, treatment or medication administration (e.g., drawing medications into syringes in precise measurements; giving a medication IV, IM, or subcutaneously using the appropriate syringe or apparatus; performing tracheotomy care and suctioning; inserting urinary catheters; creating sterile fields; sterile and clean dressing changes) and administering basic life support (BLS) cardiopulmonary resuscitation or advanced cardiopulmonary life support (ACLS), depending upon the nursing student s program level. move, transfer, and position patients or equipment safely under a variety of circumstances with or without a lift team or assistive devices during the delivery of general nursing care or in emergency situations. have the endurance to complete all required tasks during the assigned period of clinical practice in order to carry out the nursing process in the context of patient care delivery. navigate patients rooms, work spaces, and treatment areas with appropriate precision and speed to carry out the nursing process during the delivery of general nursing care or in emergency situations. V. BEHAVIORAL AND SOCIAL ATTRIBUTES Competencies: The Technical Standards include the ability to demonstrate behavioral and social attributes in academic and in oncampus clinical and off-campus clinical settings in connection with other identified professional nursing student competencies included in the AACN s Essentials of Baccalaureate, Master s and Doctoral Education for Professional Nursing Practice, the National Student Nurses Association, Inc. Code of Ethics: Part II Code of Academic and Clinical Conduct and Interpretive Statements, and NYU/NYUCN s student academic integrity policy. Rationale: Nursing student behavioral and social attributes competencies include the knowledge, attitude, and skills necessary to provide quality and safe patient care in all health care settings. Examples of behavioral and social attributes competencies include, without limitation, the ability to: conform to all requirements set forth by NYU/health care agency s affiliation agreements as well as any additional requirements of any clinical setting. uphold professional nursing standards related to the student s scope of practice. conform to NYUCN s attendance and clinical dress code/professional appearance requirements for on-campus clinical simulation and off-campus clinical learning sessions. communicate in a mature, professional, culturally sensitive, therapeutic, accurate and effective manner with patients, patients family members/significant others, members of the health care team, faculty, staff, and peers. maintain effective, appropriate, and sensitive relationships with patients, patients family members/significant others, peers, faculty, staff, and other health care professionals. work cooperatively and with honesty and integrity with peers, faculty, and members of the healthcare team. Page 4 of 5

20 adapt to changing environments and exhibit flexibility and composure in the face of uncertainties inherent in the clinical problems of diverse patients. use conflict resolution strategies effectively in University, on-campus clinical simulation, and off-campus clinical learning settings integrate constructive criticism received in University, on-campus clinical simulation and off-campus clinical learning settings. correctly judge when a nursing intervention requires additional assistance and seek help from the NYUCN clinical instructor, preceptor, or appropriate agency health care team member. I certify that I have read, understand, and will adhere to the NYUCN Technical Standards for Core Professional Nursing Competency Performance for progression in and graduation from the respective NYUCN Nursing Program. I understand that if I do not adhere to one or more of the competencies outlined in the Technical Standards, NYUCN may take one of the following actions pursuant to the Policy for Assessing Students Ability to Meet or Continue to Meet Technical Standards: 1 (a) involuntarily withdraw the student from a course(s), (b) assign the student a grade of F in the course(s), or (c) dismiss the student from the respective nursing program. Print Name NYU ID Number Student Signature Date Program Admitted: BS, MS, MS Ad. Cert., DNP, PhD (please circle one) Matriculation Term: Fall, Spring, Summer 20 (please circle the semester and insert year) Please return the signed form to: New York University College of Nursing, Office of Clinical Affairs 433 First Ave. Or fax signed page to Fax: or sign, scan, & form to nursing.healthclearance@nyu.edu Subject: TECHNICAL STANDARDS FOR CORE PROFESSIONAL NURSING COMPETENCY If you have any questions, please call the Office of Clinical Affairs at (212) See Page 5 of 5