HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES

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1 HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES Medical clearance is mandatory in order to see any patient in the clinical setting. As there is patient contact in the didactic year, clearance from a primary health care provider must be obtained prior to beginning the program. Health Clearance Forms MUST be completed and returned by May 15, 2015 Please remember that these forms must be filled out in addition to the Hofstra University Medical Record. A primary care provider must examine and order appropriate laboratory tests in order to issue clearance for medical practice. S/he must only document that you are clear on the attached Physical Exam form. In addition, the program must have documentation of the titers of each infectious diseases listed on the Immunization Form. Titers may be substituted for a recent date of immunization, although a provider simply stating that a student is immune will not. Please be sure that the provider understands this requirement. Immunization titers from past examinations may suffice for clearance; show them to the health care provider. Please review all paperwork before and after the visit. It is your responsibility to ensure that these forms are properly completed correctly. Questions should be directed to Gia Raponi at: Read all of the medical clearance documents thoroughly. Most of the paperwork is filled out by the student. Make a photocopy for your records of all of paperwork, including results of blood work, as they will need to be produced for clerkship preceptors during the clinical year. With the exception of immunization information and tuberculosis screening results (PPD and/or CXR), the PA faculty and staff are unable to review student medical records. Therefore, do not submit any documentation or test results that do not pertain to immunization or tuberculosis screening. If other lab results are documented by your provider, please white these out and make a copy for submission to the program. Likewise, a full medical history and physical examination should not be submitted to the program. The program is only allowed to review information documented on Parts I-II, and then only with written student permission. A consent form is enclosed. Please review and sign it, if you consent. All students are required to carry health insurance. Some clerkship sites require evidence of health insurance before permitting a student to begin the rotation. Therefore, the insurance information must be accessible at all times. The Health and Wellness Center, Hofstra University, Republic Hall, North Campus: hofstra.edu/studentaffairs/studentservices/welctr/index.html ( ) provides information regarding insurance plans. If a health condition arises during the course of study that would in any way

2 alter the ability to perform in the clinical setting, the student is responsible to notify the director of the program immediately. STUDENT INSTRUCTIONS FOR HEALTH CLEARANCE Student Health Clearance Form (Parts I and II) is completed by a health care provider. 1) Measles (Rubeola), Mumps, Rubella and Varicella titers are required (A titer is a dilution ratio. Documentation of immunity without the titer is not acceptable). For each of the four diseases, a student must provide evidence of a positive titer. The titer results must be documented on Part I: Immunization Record. A copy of the laboratory report showing the positive NUMERIC titer must be submitted. If the titer does not demonstrate immunity, documentation of the administration of immunization must be submitted on: Part I: Immunization Record. Additionally, a copy of the patient record or a written letter from the health care provider documenting the date, type, and dose of the immunization(s) is required. 2) A tetanus/diphtheria/pertussis (Tdap) immunization administered within the last 10 years is required. This is documented on Part I: Immunization Record. CDC guidelines mandate: All health care providers who have not or are unsure if they have previously received a dose of Tdap should receive a one-time dose of Tdap as soon as feasible, without regard to the interval since the previous dose of Td. Then, they should receive Td boosters every 10 years thereafter. 3) Hepatitis B vaccines are strongly recommended by the program, and required by a number of clinical sites. If not immune, the series takes approximately 6 months to complete. Therefore it is important to begin the process now. Guidelines for Hepatitis B are as follows: o A positive Hepatitis B surface antibody titer (quantitative), documented on Part I: Immunization Record. A copy of the lab results with the positive titer must be submitted. OR o If the titer does not demonstrate immunity, documentation of the administration of the threeseries immunization must be submitted on: Part I: Immunization Record. Additionally, a copy of the patient record or a written letter from the health care provider documenting the date, type, and dose of the immunization(s) is required. The schedule of immunizations should be included in this note. 4) The date and results of the Tuberculin Skin Test (PPD) are required annually. Acceptable documentation includes a copy of the patient record, PPD card, or a written letter from the health care provider stating the date and result of the PPD. o History of BCG vaccination is NOT a contraindication to PPD testing. A false-positive PPD secondary to prior BCG vaccination will necessitate Quantiferon-TB Gold testing to demonstrate negativity. If Quantiferon-TB Gold testing is necessary, this will need to be repeated annually in lieu of a PPD.

3 5) A history of a positive PPD without BCG vaccination necessitates the following: 1) documentation of the positive PPD (letter from health provider or copy of patient record), 2) chest X-ray results, within one year 3) documentation of the details of prophylaxis, if applicable. Clinical rotation sites require additional PPD s during the clinical year, so all records should be retained. 6) Physical Exam: A complete physical exam must be performed by a primary health care provider. Documentation should only state the information on form PART II. A full medical history and physical examination should NOT be submitted to the program. Please make sure that the medical clearance part of the form is completed by the health care provider. 7) Consent Form: The student consent form allows program faculty and staff to maintain and release immunization and tuberculosis screening results to clinical sites as needed. Please read the consent form, sign, and return it to the program if you authorize the program to keep these records. If you chose not to, the student will be responsible for maintaining and providing these records to each site as the need arises.

4 HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES PART I: IMMUNIZATION RECORD _ Student Name Date of Birth Student Hofstra ID (700#) Parts I and II must be completed by a health care provider Measles, Mumps, Rubella and Varicella Immunizations and Titers: If titers demonstrate immunity, please write titer result only. If titers do not demonstrate immunity, document the date of immunization. In all cases, a copy of the NUMERIC titer results must be attached. Measles (Rubeola) If immune, Titer results OR if not immune, vaccine dates #1_ #2_ (attach copy of laboratory test indicating immunity.) Mumps If immune, Titer results OR if not immune, vaccine dates #1_ #2_ (attach copy of laboratory test indicating immunity.) Rubella If immune, Titer results OR if not immune, vaccine dates #1_ #2_ (attach copy of laboratory test indicating immunity.) Varicella If immune, Titer results OR if not immune, vaccine dates #1_ #2_ (attach copy of laboratory test indicating immunity.) Tdap: Must be within the last 10 years. Tdap - date of vaccine Hepatitis B: Hepatitis B If immune, Titer results OR if not immune, vaccine dates #1_ #2_ #3 (attach copy of laboratory test indicating immunity or a copy of signed waiver if non-reactive.) Tuberculosis skin test (PPD): Must be within the last year Date of test result If positive: Date of test result mm Results of Chest X-ray_ date of chest x-ray_ INH therapy yes no date of INH If prior BCG, Quantiferon-TB Gold: Date Result _(attach Chest X-ray results) Signature and stamp of health care provider Date

5 HOFSTRA UNIVERSITY DEPARTMENT OF PHYSICIAN ASSISTANT STUDIES STUDENT HEALTH CLEARANCE FORM PART II: PHYSICAL EXAMINATION Student Name: Date of Birth: A thorough exam was completed on the above named individual. I find him/her to be in good health. She/he is free of any health impairments which may pose potential risk to patients or personnel, or which may interfere with the performance of clinical responsibilities. Habituation to alcohol or other drugs which may alter the individual s behavior has been considered in this evaluation. Signature of examining health care provider Print Name Date Telephone number ***This form should not be signed unless the individual is able to fully participate in the education process at Hofstra s physician assistant program. *** Medical Clearance After a review of all health information I certify that this student is found to be in good physical and mental health and appears able to perform physician assistant student responsibilities with or without accommodations. Practitioner s name (print): Practitioner s signature: Practitioner s stamp:

6 Consent for Release of Confidential Health Information Student Name: Date: I, hereby authorize The Department of Physician Assistant Studies at Hofstra University, to release all or part of my medical record to the clinical sites in which I am assigned. I hereby authorized faculty and staff of the program, to maintain and release immunization and tuberculosis screening results. I understand that all other medical records will remain confidential and will not be accessible to or reviewed by program faculty or staff. (Student Signature) (Date)

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