Gaston College Student Health Records - Requirements and Accommodations

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1 Student Health Information Welcome to Gaston College! We are so glad that you have chosen to complete your education in one of our outstanding health programs. All Health Program students are required to submit to the college a student Health Record. Below are detailed instructions and more information for your understanding. PLEASE NOTE: Students must retain a copy of all documentation submitted to the Compliance Specialist. All records must be verified with a healthcare provider s signature or stamp. Students will be ineligible to participate in Clinicals until the Health Record is completed. SUBMISSION OF STUDENT HEALTH RECORD Submission Deadline When applying to your chosen program, please submit the completed Health Form on or before the designated due date. Three Ways to Submit Health Record: 1. Deliver to the Dallas Campus 1. Hand deliver your health records to the Dallas Campus (David Belk Cannon Building) Compliance Specialist, Danielle Kahne, office # Mail to the Dallas Campus 2. Danielle Kahne, Compliance Specialist Gaston College 201 Highway 321 South Dallas, NC Scan Documents and to 3. to: kahne.danielle@gaston.edu the Compliance Specialist If you have questions, Contact Danielle Kahne, Compliance Specialist at CRIMINAL BACKGROUND CHECK REQUIREMENTS Please note that all students must complete a criminal background check. Instructions Failure to Report As a requirement from our clinical agencies, we must ensure this is completed for every student. Gaston College endorses the following source for obtaining a criminal background history: 1) Go to 2) In Place Order enter package code for your school ( ) 3) Click Go and follow instructions. 4) ANY allegations or charges of a misdemeanor or felony that occur after the Criminal Background History results have been submitted must be reported immediately to the Compliance Specialist, Danielle Kahne. Clinical Sites have the right to deny students access based on criminal background. This denial would result in the student s inability to complete the program of study successfully. Failure to report any change may result in withdrawal or removal from the program.

2 HEALTH INSURANCE/MALPRACTICE INSURANCE & CPR Health Insurance All students are required to have health insurance coverage. Coverage is required throughout enrollment in the program. Acceptable Sources to Obtain Health Insurance Malpractice Insurance (Tuition Fee) CURRENT American Heart Association CPR (Adult, Child, Infant) There are many sources from which to obtain health insurance coverage, a few examples include: Medicaid, Affordable Care Act, Military Insurance, BCBS, Aetna, Cigna, United Healthcare, etc. Healthcare coverage is also offered by the NC Community College System at Malpractice Insurance (required for Nursing and Health Services program students): $13 per year Proof of current American Heart Association Healthcare Provider CPR certification must be on file and current at all times. PHYSICAL EXAMINATION BY A HEALTHCARE PROVIDER (FORM A) Examination by Healthcare Provider (Using Form A Student Health Evaluation) Hearing and Color Vision Tests Signatures/Facility Stamp Only a physician, physician assistant, or nurse practitioner shall perform the physical examination. Hearing and vision tests must be included as part of the physical examination. Vision test must include a color vision test due to clinical skills where visualization of color is necessary to patient care. The Physical Examination and Immunization Record forms must include the healthcare provider s signature and the address/phone number of the facility. PROGRAM ESSENTIAL FUNCTIONS/COMPETENCIES (FORM B) Program Essential Functions (Form B) Submission of the Program Essential Functions Form Each Program has a list of competencies which students must be able to perform in order to successfully complete the learning outcomes. Only a physician, physician assistant, or nurse practitioner shall perform this section. IT MUS BE SIGNED BY A QUALIFIED HEALTHCARE PROVIDER! The Essential Functions Form will need to be sent to our Compliance Specialist, Danielle Kahne, by any of the following means: 1. Hand deliver 2. kahne.danielle@gaston.edu 3. Mail Danielle Kahne, Compliance Specialist Gaston College 201 Highway 321 South Dallas, NC SPECIAL NOTE: North Carolina State Law Section 15A NCAC 19A.0207 (POSITIVE HIV and HEP B infected). This law addresses HIV and HEP B infected healthcare workers (THIS INCLUDES STUDENTS IN HEALTH PROGRAMS.) Excerpt: (b) All health care workers who perform surgical or obstetrical procedures or dental procedures and who know themselves to be infected with HIV or Hepatitis B shall notify the State Health Director. The notification shall be made in writing to the Chief, Communicable Disease Control Section,P.O. Box 27687, Raleigh NC WHERE APPLICABLE: Gaston College students are required to comply with this notification.

3 IN THE EVENT THAT A STUDENT DOES NOT MEET PROGRAM ESSENTIAL FUNCTIONS Disability Services: If a Gaston College Health Services Program Applicant or current student believes that he or she cannot meet one or more of the essential standards without accommodations or modifications, the college must determine, on an individual basis, whether or not the necessary accommodations or modifications can be reasonably accommodated. Requests for accommodations should first be directed to the program chairperson and/or coordinator. From there the Counseling and Career Development Center at Gaston College will assist and advise students with documented disabilities, arranging academic support and reasonable accommodations. Accommodations are arranged on an individual basis, specific to the student s needs. Students must provide all necessary documentation prior to receiving any special accommodations. Change/Altered State of Student Health after Admission to a Health Program: A change in the student s health during the program of learning, so that the essential functions cannot be met, with or without reasonable accommodations, may result in withdrawal from the Health Sciences Program. The chairperson/coordinator of the program must be informed when there is any change in condition/health of students (for example: pregnancy, injury, extended illness, hospitalization). An additional medical examination at the student s expense may be required in order to assist with evaluation of the student s ability to perform the essential functions of the Health Sciences Programs at Gaston College. IMMUNIZATIONS All Programs EXCEPT VET TECH will need to provide proof of the following vaccines/immunizations. (Form C) VET Tech Student Immunizations DPT or TD (must have a total of 3) OR Tdap within 10 years Polio MMR (Measles, Mumps and Rubella) 2 doses or titers Hepatitis B (3 shot series) or declination Varicella Titer (Chicken Pox) 2 step PPD (on admission) Annual TB test Seasonal Flu Vaccine (mandatory in most clinical sites) - Rabies Vaccine - Tetanus & Pertussis Vaccine (Tdap within 10 years) To learn more information about these vaccines and the benefits/potential risks, please visit the Center for Disease Control and Prevention website at NOTE: Vaccine requirements may change based upon industry standard and/or Center for Disease Control recommendations. All students will be informed in a timely manner about any changes in required immunizations for admittance and/or progression in a health program at Gaston College.

4 DRUG SCREEN REQUIRMENTS Drug Screen Requirements Gaston College adheres to the policies and procedures of all clinical facilities with which the health programs are affiliated for student clinical learning experiences. These policies and procedures address the requirement for a drug screen and circumstances when policies are not followed. 12 Panel Drug Screen *THC Marijuana * PCP (Phencyclicline) *BAR (Barbituates) *BZP (Benzodiazepines) *PPX (Propoxphene) *COC (Cocaine) *MTD (Methadone) *OPt (Opiates/Including Heroin *OXY (Oxycodone) *AMP (Amphetamines) *MDMA (Ecstasy) *METH (Methamphetamines) Positive Drug Screen Due to Prescribed Medications Positive Drug Screen Due to Non-prescribed Medications and/or drugs. A POSITIVE drug screen due to prescribed medications must be substantiated by documentation from the prescribing physician. A POSTIVIE drug screen due to non-prescribed drugs will result in the student being ineligible to participate in a clinical experience. The student will be withdrawn from the program. Sources for Drug Screen Testing Drug Testing is offered in coordination with an outside laboratory. You will be given information of how to obtain drug sceening through our Compliance Specialist, Danielle Kahne. Results of Drug Screens Results will be kept onsite at Gaston College and available for review in order to be in compliance with our clinical facilities, policies and procedures, and clinical agency contracts.

5 Student Health Record Student Name: Last First Middle Gaston College Student ID # Date of Birth Mailing Address: Street Address City State Zip code Phone Numbers: Home# Cell # Gaston College Address: Emergency Contact Information: (In the event of an emergency) Name: Relationship: Phone Numbers: (Home) (Cell) (Work) Program: (Please check which program you are entering) Associate Degree Nursing (Traditional) Associate Degree Nursing (LPN-RN) Cosmetology Dietetic Technician and/or Dietary Manager Medical Assisting Nursing Assistant Phlebotomy Practical Nursing (LPN) Therapeutic Massage Veterinary Medical Technology

6 STUDENT PHYSCIAL/HEALTH EVALUATION (Form A) (Healthcare Provider to Complete This Form MD, PA, NP) Student Name: Date of Birth: (month/day/year) / / Height: Weight: Blood Pressure: Vision: Corrective Lenses Hearing: WNL Color vision: Is student color blind? Hearing Aids Used: Please indicate below if the prospective Health Sciences Program student has any problems with the following body systems. Body System Normal Abnormal Describe Head, Ears, Nose, Throat Eyes Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Metabolic/Endocrine Neuropsychiatric Skin A. Is the student currently under treatment for any medical or emotional conditions? If yes explain: B. Does the student have any life threatening allergies? If yes list allergen: C. Does the student require use of Epipen? D. Does the student require any other prescribed medications for life threatening allergies? If "Yes" list medications required: Facility/Office Stamp: Signature of MD/PA/NP: Date:

7 STUDENT PHYSICAL/HEALTH EVALUATION (Form B) Gaston College Health Programs Essential Functions: Core Performance Standards for Admission and Progression (FORM B) Please read and check yes or no to each function listed! Function Standard Some Examples of Necessary Activity (Not all inclusive) Critical Thinking Interpersonal Communication Mobility Motor Skills Hearing Visual Tactile Weight Bearing Temperament & Emotional Control Critical thinking ability sufficient for clinical judgment and decision making. Interpersonal abilities suffi cient to interact with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds. Communication abilities sufficient for interaction with others in verbal and written form. Physical abilities suffi cient to move from room to room, maneuver in small spaces, transport patients and animals in VET tech program as needed for care. Gross and fine motor abilities sufficient to provide safe and effective care. Auditory ability sufficient to monitor health needs of patient/client. Visual ability sufficient for observation and assessment necessary in patient/client care. Tactile ability sufficient for physical assesment. Lifting ability sufficient for a variety of patient/ client care settings. Remain calm, patient, and react professionally to certain situations. Identify cause and effect relationships in clinical situations, carry out care of client/patient correctly. Establish rapport with clients, patients, caregivers, and colleagues. Explain treatment procedures, initiate health teaching as directed, document care, interpret re-sults, and communicate with other caregivers with or without reasonable accommodations. Moves around in patient/animal care rooms, work spaces,and treatment areas. Administer cardio-pulmonary procedures with or without reasonable accommodations. Calibrate and use equipment, position client/patient with or without reasonable accommodations. Hears monitor alarms, emergency signals, auscultatory sounds, cries for help, with or without reasonable accommodations. Observes patient/client responses to care with or without reasonable accommodations. Perform palpation, functions of physical examination and/or those related to therapeutic intervention, i.e., insertion of IV s, catheter with or without reasonable accommodations. Performs patient/client care that demonstrates the ability to lift and manipulate at least 50 pounds. *For EMS program, able to lift and manipulate at least 170 lbs. High stress clinical areas, working with others in healthcare (TEAM centered). I have read the program essential functions and based on my assessment of this student s physical and emotional health on (date), he/she is able to participate in the activities of this program in a classroom, clinical, and lab setting. Facility/Office Stamp: Signature of MD/PA/NP: Date:

8 Immunizations Record (FORM C) Clinical Agency Requirements/Proof of Vaccinations Student Name: Student ID #: Date of Birth: (Month/day/year) / / To be completed and signed by physician and/or clinic. A complete immunization record is required and must be met in order to proceed in the program. REQUIRED IMMUNIZATION DPT (Diphtheria, Tetanus, Pertussis) Tetanus Booster (Within 10 years) MMR (Measles, Mumps, Rubella) Hepatitis B OR Declination Form MO/DAY/YEAR MO/DAY/YEAR MO/DAY/YEAR MO/DAY/YEAR #1 #2 #3 #1 #2 Varicella (Chicken Pox) series of two doses or titer #1 #2 Tuberculin Skin Test (PPD) *If PPD is positive a one time chest x-ray is required (chest x-ray documentation to include date, results, and recommendations for future testing). Date of 2 step PPD #1 #2 OR Titer date & results (attach proof) #1 #2 #3 Titer date & results (attach proof) OR Titer date & results (attach proof) Attach proof with date and results of PPD. Results of PPD Flu/Influenza Vaccine SEASONAL VACCINE Date Received Month/Year Flu/Influenza Vaccine RABIES Vaccine for VET Tech Students ONLY Facility/Office Stamp: Signature of MD/PA/NP: Date:

9 Student Signature Page (Form D) PART I: STUDENT NOTICE/HEALTH EDUCATION PROGRAMS I, the undersigned student in a health program at Gaston College, understand that participation in a clinical experience is a requirement to complete my program successfully. (Please initial that you understand each requirement and have had your questions answered regarding these requirements. Criminal Background Check and Fingerprinting Obligation to Report Criminal Charges Drug Testing Healthcare Provider signed form/physical and emotional stability for program essential functions Obtain and maintain up-to-date CPR Certifi cation Off-Campus Release of Emergency Contact Information PART II: AUTHORIZATION FOR OFF-CAMPUS CLINICAL RELEASE Authorization for Disclosure: Off-Campus/Clinical Facility Release of Student Health Information Off-campus clinical facilities may require medical information on students in programs with clinical assignments. Gaston College is responsible for providing the clinical facility with medical data abstracted from the student s medical record. This data may include vaccinations received, medical test results, criminal background screens and drug screen results. The facility may also require that the student provide a copy of their medical packet if necessary including emergency contact information for first aid and safety purposes if medical treatment is required. By signing below, I authorize Gaston College and the Health Division to release and disclose any and/or all pertinent medical information as indicated in the above provision, to an affiliating clinical facilities that require this information as a condition of my assignment to the facility. I understand that if I refuse to release my medical information to Gaston College /clinical facilities I may lose my eligibility to continue as a student in Gaston College Health Programs. I further understand that failure to release the records may result in the facility denying my clinical assignment. I also understand that I may not be able to fulfill the Program s graduation requirements. Student Signature: Date: