RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET

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1 School of Nursing-Camden Rutgers, The State University of New Jersey Residence Hall 215 North 3 rd Street Camden, NJ nursing.camden.rutgers.edu Phone: Fax: RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET Nurses have a professional obligation to ensure patient safety. Attached is the required Health Records packet that Rutgers School of Nursing - Camden requires to be completed prior to starting the Nursing Program. Please note that you cannot attend clinical experiences if your health records are incomplete.. You should complete these requirements as soon as possible due to the amount of time involved in obtaining titers and scheduling immunizations. You may have your physical performed at your primary healthcare provider or Student Health Services. They will provide physical examinations and blood work with a scheduled appointment. They will also provide a nurse review of all of your health records for completion. For more information, please visit their website at or call them at to schedule an appointment. All students are required to submit proof of an annual PPD (or chest x-ray). Proof of annual influenza immunization is required by November 1. Submit health records as they are completed. The Hepatitis B injection series may be submitted as you receive them. YOU MUST USE THE FORMS SUPPLIED IN THIS PACKET; NO SUBSTITUTIONS! PLEASE UPLOAD THIS FORM ONCE COMPLETED TO YOUR STUDENT TRACKER AT: USING THE LOGIN INSTRUCTIONS SENT TO YOU BY YOUR ADVISOR PLEASE NOTE: All Rutgers University Immunizations requirements for admission must be turned in to Health Services (MMR, Hepatitis B series, Meningitis-if living on campus, and TB if you are an international student). These are RU requirements for graduation, and are needed in addition to scanning the documents into the Castle Branch Tracking System! Revised 5/2016 RU:C SON

2 Rutgers School of Nursing Physical Examination Record [ ] Traditional [ ] Accelerated [ ] RN/BS [ ] School Nurse [ ] DNP [ ] Faculty Permanent Mailing Address Zip Telephone # - - of Birth / / PHYSICAL EXAMINATION REPORT (Complete All Items) Height Weight Blood Pressure Pulse Vision: with correction R 20/ L 20/ without correction R 20/ L 20/ Findings: is able to function in clinical experiences with the Appearance Nutrition Skin Head/Neck Glands Eyes Ears Nose Mouth/Teeth/ Throat Chest Lungs Heart Abdomen Back Musculo-skeletal Testes Genitalia/Pelvic (Optional) Neurological Normal Abnormal Description of Abnormal Findings following restrictions: None Other Signature MD; DO; APRN

3 Last, First MI This section is to be 100% completed and signed by a licensed healthcare provider. VACCINE Dose #1 Dose #2 Dose #3 HEPATITIS B (ADULT) REQUIRED 3 doses followed by titer / / / / / / of positive immune Titer Titer attached TDAP (Tetanus, diphtheria, and acellular pertussis) s of initial series and boosters ( booster must be within past ten years / / of most recent booster Varicella s of 2 vaccines, or positive titer attached. / / / / MMR (Measles, Mumps, Rubella) s of 2 measles vaccines (measles or MMR) given after your first birthday; or positive blood titer attached / / / / Titer attached Titer attached Healthcare Provider Name, Address and Signature, Degree / / Provider Signature and Degree Return Form to: Upload all completed health forms and titers to your Castle Branch student tracker.

4 Copy of the following lab results must be attached in addition to dates on lab page: Required Titer: Hepatitis B Surface Antibody (4 8 weeks after final immunization) A copy of lab result must be attached : Rubella titer Rubeola titer Mumps titer Varicella If you have documentation of the 2 vaccines, a titer is not required. If you have had a case of Varicella, you will still need either documentation of the 2 vaccines or a titer. *** There is no expiration on titers. Upload all completed health forms and titers to your Castle Branch student tracker.

5 Verification of Annual Influenza Immunization Administration Influenza vaccine TO BE COMPLETED BY HEALTH CARE PROVIDER: Vaccine Administered / / Vaccine Manufacturer: GlaxoSmithKline; Other Vaccine Lot Number Expiration : Site of Injection: Left Right DELTOID Route: IM Record any reaction observed in the first 20 minutes after vaccination administration: Provider Signature/: / / Upload all completed health forms and titers to your Castle Branch student tracker.

6 Verification of Annual PPD Administration PPD Skin Test Information A two-step PPD is required (7-30 days apart), unless you have documentation of a negative PPD in the past 12 months. TO BE COMPLETED BY HEALTH CARE PROVIDER: This section MUST be completed and signed by a licensed health care provider. Please provide the information below: test administered (MM/DD/YYYY): test read (MM/DD/YYYY): Reading/Result in millimeters induration: test administered (MM/DD/YYYY): test read (MM/DD/YYYY): Reading/Result in millimeters induration: If PPD positive, complete TB questionnaire. You will need to indicate date of conversion, post conversion chest X-ray and treatment received. Attach copy of chest X-ray report. Name of health care provider (printed): Provider Signature/: / / Provider s phone number: ( ) Upload all completed health forms and titers to your Castle Branch student tracker.

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