Failure to submit this completed form with correct documentation by the deadline may result in loss of your seat in the nursing major.

Transcription

1 INSTRUCTIONS F SUBMITTING ANNUAL PRELICENSURE HEALTH, INSURANCE, AND EDUCATION REQUIREMENT FM STUDENTS ADMITTED IN THE FALL SEMESTER-Deadline for postmark of these completed forms and supporting documentation for fall is July 7th. Must be hand delivered by July 17th to the Department of Nursing office in Barratt Hall 124 if you do not meet the July 7th postmark deadline. STUDENTS ADMITTED IN THE SPRING SEMESTER- Deadline for postmark of these completed forms and supporting documentation for spring is November 24th. Must be hand delivered by December 1st to the Department of Nursing office in Barratt Hall 124 if you do not meet the November 24th postmark deadline. Send to: Lander University Department of Nursing, 320 Stanley Avenue, Greenwood S.C This form WILL NOT BE ACCEPTED unless ALL required documentation is attached. *Faxed/ ed copies to the Department of Nursing will NOT be accepted. (Readable photocopies of original documents are accepted.) ALL documentation must cover the entire academic year. Please keep a copy of all documents for your records. (Department of Nursing copying charge is $1.00 per page). Failure to submit this completed form with correct documentation by the deadline may result in loss of your seat in the nursing major.

2 LANDER UNIVERSITY DEPARTMENT OF NURSING ANNUAL PRELICENSURE HEALTH, INSURANCE, AND EDUCATION REQUIREMENTS NAME: LANDER ADDRESS L# PHONE # Failure to submit this D form with ALL correct documentation by the deadline may result in loss of your seat in the nursing major. 1 HEALTH & ACCIDENT INSURANCE Proof of medical insurance covering you for the entire academic year (ending in May). Students will only need to provide proof if there has been a change in provider since last year. No Change Name of Insurance Company Annual/ Changes noted My health and accident insurance has changed since last year. I have: Attached is a copy of the face sheet ONLY of the policy Attached is a copy of front & back of the insurance card Name of Insurance Company Date of Coverage Date of Coverage 2 PROFESSIONAL NURSING STUDENT LIABILITY INSURANCE: Annual Submission or longer depending on initial effective dates. Students are required to have professional liability insurance coverage annually in amounts not less than $1,000,000 per occurrence; $3,000,000 in aggregate effective throughout the academic year. 3 CPR CERTIFICATION All students must show evidence of certification in CPR throughout the academic year. The American Heart Association s HEALTHCARE PROVIDER BLS Course C* course is the ONLY course ACCEPTED. *If insurance was renewed this is a change. Start Date of Coverage Expiration Date *If CPR was renewed this is a change. Date of Certification Date of Expiration *NOTE: Submit a copy of your CPR card when received to the Department of Nursing office Attached is a copy of the face sheet ONLY of the policy showing coverage dates & coverage amounts Attached is a copy of my receipt and the front page ONLY of the application showing coverage dates & coverage amounts Start Date of Coverage Expiration Date Attached is a copy of the front & back of my CPR Certification Card American Heart Assoc. Healthcare Provider BLS Course Attached is a copy of a letter from my CPR Instructor validating successful completion of Healthcare Provider or Professional Rescuer course. Date of Certification Date of Expiration *NOTE: Submit a copy of your CPR card when received to the Department of Nursing office.

3 4 Current PPD (Tuberculin Test) An Annual PPD is required. Proof on signed agency letterhead, prescription pad or doctor s order showing date and results of PPD in mm of induration and name of agency where it was completed. Attached is a copy of signed record of my current PPD showing date placed and date read and results. Date Placed Date Read 5 Tetanus/Pertussis: (Tdap) Must submit proof upon expiration. Proof of a tetanus/pertussis booster given within the last ten (10) years. 6 Annual Health Update Form Health update must be completed annually by student. 7 Criminal Background Check and Drug Screening Drug Screen must be done within 90 days prior to beginning nursing courses. Please allow 1-3 business days to receive your Registration . Our clinical agencies require a criminal records check be conducted of all direct patient caregivers (including nursing students) in nursing homes, day care facilities for adults, home health agencies, and community residential care facilities. Some clinical agencies also require drug screening of all nursing students. Therefore, these are required of all nursing students annually. Instructions for completing the Criminal Background Check and Drug Screening can be found at Date of Vaccine *NOTE: Students should retain copies of all receipts in case proof of completing background check and/or drug screen need to be presented to the Department of Nursing. Attached is a copy of record showing tetanus booster given within the last ten (10) years. Date of Vaccine Attached is a completed and signed Annual Health Update form Date of Completion I certify to the best of my knowledge that the above information is true and complete with all documentation attached. I authorize the Department of Nursing to release this information to the agencies where I have clinical laboratories. DATE: STUDENT SIGNATURE

4 PRELICENSURE ANNUAL HEALTH FM (to be completed by student) FAILURE TO SUBMIT THIS D FM BY THE DEADLINE WILL RESULT IN LOSS OF YOUR SEAT IN THE NURSING MAJ. NAME: ACADEMIC YEAR - L #: DATE OF BIRTH: / / LOCAL PHONE: ADDRESS: Indicate if you have ever been diagnosed or treated for any of the following. Provide additional information as indicated. CIRCLE Y= yes; N= no 1. Asthma or other respiratory problems Y N 2. Diabetes Y N 3. Low blood sugar Y N 4. Cardiac problems Y N 5. High blood pressure Y N 6. Kidney problems Y N 7. Bladder problems Y N 8. Fainting/dizziness/loss of consciousness Y N 9. Seizures ; (if yes, date of last seizure. Date: ) Y N 10. Problems with vision (provide information on back of form) Y N 11. Do you wear glasses? Y N 12. Contact lenses? Y N 13. Problems with hearing (provide information on back of form) Y N 14. Do you use a hearing device? Y N 15. Musculoskeletal problems (provide information on back of form) Y N 16. Does this problem limit mobility or lifting? Y N NA 17. Other neurological/sensory problems (gait, smell, touch, etc) Y N 18. Blood disorders (sickle cell anemia, hemophilia, etc) Y N 19. Other medical or psychiatric conditions Y N (provide information on back of form) 20. Are you under medical care for the conditions circled above? Y N 21. Have you had any significant health changes in the last 12 months? Y N If yes, explain (provide additional information on back of form) 22. Latex Allergy Y N 23. Describe your general health (circle): Excellent Good Fair Poor 24. List drug, food, or other allergies and any medical attention that is immediately required: Name & phone # of healthcare provider: EMERGENCY CONTACT INFMATION: (Name) (Phone number) In case of emergency, I give Lander Department of Nursing permission to obtain medical assistance and to notify my emergency contact person(s). Yes No (initial) By my signature below, I verify that the information provided on this form is a true and accurate report of my health status. SIGNATURE: DATE: I AUTHIZE THE DEPARTMENT OF NURSING TO RELEASE THIS INFMATION TO THE AGENCIES WHERE I HAVE CLINICAL LABATIES. (Signature of Student) (Date) Approved by NFO 2010; Revised 5/3/2011; 7/2012

5 INSTRUCTIONS F COMPLETING ANNUAL HEALTH, INSURANCE, AND EDUCATION REQUIREMENT FM 1. HEALTH & ACCIDENT INSURANCE Health and Accident Insurance is required of all nursing students. You must attach a copy of the face sheet (only) of the policy a copy of your insurance card (front and back). 2. PROFESSIONAL NURSING LIABILITY INSURANCE All nursing students are required to have Professional Nursing Liability Insurance coverage in the amounts not less than $1,000,000 per occurrence; $3,000,000 aggregate effective throughout the academic year. Attach a copy of the face sheet (only) of the policy showing coverage dates and amounts or a copy of the receipt and face sheet of the application showing coverage dates and amounts. (Suggestions of Professional Nursing Liability websites can be found on the Department website ( 3. CPR CERTIFICATION All nursing students must show evidence of certification in CPR throughout the academic year. The American Heart Association BLS Course is the ONLY course accepted. Attach a copy of your AHA BLS Course CPR card (front and back). 4. PPD (Tuberculin Test) Annual current PPD is required annually. Attach a copy of proof on signed agency letterhead, prescription pad or doctor s order showing date and results of PPD in mm of induration. Attach copy of documentation copy of annual chest x-ray report if PPD was positive in the past. 5. TETANUS/PERTUSSIS (Tdap) Attach a copy of record showing proof of a Tetanus/Pertussis booster given within the last 10 years. 6. ANNUAL HEALTH UPDATE FM The Annual Health Form must be completed in its entirety by 2 nd semester sophomores, juniors and seniors. (All questions and dates be completed or the form will be returned.) 7. CRIMINAL BACKGROUND CHECK AND DRUG SCREENING Drug Screen must be done within 90 days PRI to beginning nursing courses. Please allow 1-3 business days to receive your Registration . Annual Criminal Background Check & Drug Screening must be completed by all nursing majors. Instructions for completing the Lander Department of Nursing Criminal Background Check and Drug Screening can be found at After completing the on-line ordering process, American DataBank will you a Registration ID Number and the location of the closest Quest Diagnostics Patient Service Center to your address. South Carolina residents select Package 1: Comprehensive Background Check AND Ten Panel Drug Screen. Out of State residents select Package 2 and 3: Criminal Background Check AND FBI Fingerprint plus Ten Panel Drug If you have questions about the criminal background check & drug screening, contact American DataBank, Customer Service, phone: or Approved by NFO 2010: Revised 5/3/2011; Revised 12/2011;