Delaware County Community College Allied Health, Emergency Services, & Nursing Nursing Program Medical Requirements

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1 Allied Health, Emergency Services, & Nursing Nursing Program Medical Requirements ******All Forms Due by the First Monday in July***** Program Requirements Matriculation into the Nursing Program and most of the Allied Health programs requires a physical exam, CPR certification, drug screening, and insurance. Please review the details, listed below, of each of these requirements. These requirements must be completed and forms submitted to certifiedbackground.com. Please know there will be a fee for the Drug Test and additional fees for specific requirements will be assessed by certifiedbackground.com. Physical Examination Check here when Complete Physical Examination. Your healthcare provider (physician, physician assistant, or nurse practitioner) should note this on the statement of good health attached to this document. Including: - 10-Panel Urine Drug Screen. - The QuantiFERON-TB gold blood test This Blood Test is preferred over the 2- step Mantoux skin test (Result must be documented). However, we will accept the 2 step Mantoux. The Quantiferon- TB is a blood test and does not require the student to make multiple trips to the office. Also, test is more accurate in diagnosing TB. (The QuantiFERON -TB Gold is a blood test for use as an aid in diagnosing Mycobacterium tuberculosis infection- both latent tuberculosis infection and active tuberculosis disease). The QuantiFERON -TB Gold is preferred over the 2- step Mantoux. However, students may choose get the 2 Step Mantoux (PPD) Test. Copies of the reports must be written on this document. Immunizations: 1. Current DTaP immunization (within a ten year period). Check here when complete 2. MMR Vaccination (Measles, Mumps, Rubella). Check here when complete *ALL entering students must have two doses; the second dose must be after If you cannot document vaccination, you must be immunized or prove immunity with a titer level. *Students born in the U.S. on or before 12/31/56 are considered immune for measles and rubella (German Measles). 3. Varicella Vaccination (Chicken Pox) (Vaccination Date must be noted on the immunization record attached) OR Varicella Titer level to prove immunity Check here when Complete 4. Record the most recent Polio vaccination date (Use the date the student started 1 st grade). Check here when Complete 5. Proof of seasonal influenza vaccination will be due in the Fall semester when the new vaccination is released for this year. Students are not required to submit this document until Oct. 31 st. 6. Recommended - Hepatitis B Vaccine. If you choose not to get this vaccine, you must sign the waiver on page. Check here when Complete CPR Certification- Check here when Complete CPR -Must be the Full Course for the Health Care Professional. Pick one of the 3 below. The certification must be valid through May 31 of the following year. Be sure to scan both sides into your certifiedbackground.com American Heart Association "Health Care Provider" (Available at DCCC- Call to get enrolled ) American Red Cross "Course for the Professional" American Safety & Health Institute Professional Level CPR/AED Personal Health/Accident Insurance Check here when complete You must have personal Health/Accident Insurance through May. List the company name and policy number. Information about a short-term policy is available from the Wellness Center. You must sign the Statement of Commitment form that is attached. If you have questions, contact the DCCC Nursing Office at Please make a personal copy of all forms for your future use prior to submitting them. DCCC: 10/2012, 12/2012, 02/2014, 05/2015 1

2 Allied Health, Emergency Services, & Nursing Medical Requirements Based on our affiliate contracts, the College may be asked to provide information on the results of immunizations and/or testing for infectious disease within the parameters of the Family Education and Privacy Act. Clinical affiliates may require copies of your medical records, drug screening results, seasonal influenza vaccination, criminal background check, and/or child abuse clearance. Additionally, you may be asked to verify absence of active communicable disease. By my signature below, I grant Delaware County Community College permission to release my medical records, drug screening results, seasonal influenza vaccination, criminal background check, and/or child abuse clearance if so required by the college s clinical agencies. I acknowledge my consent is voluntary and that these requirements are not requirements of the College but of the facilities and medical care providers the College is affiliate with for clinical programs. Student Signature: Date Name: Last, First, Middle Sex: M F (Print Legibly) Address: Street, City, State, and Zip Home Telephone # Work Telephone # Student ID # P00 Date of Birth Emergency Contact (Relationship To Student) Name and address of Emergency Contact Students Health Insurance Information Policy Name: Policy Number: 2

3 Allied Health, Emergency Services, & Nursing Medical Requirements Immunization Record Name: First, Middle, Last: Sex: M F Vaccine/Labs Tuberculosis Preferred Test- QuantiFeron Gold TB OR Date MM/DD/YY Date MM/DD/YY Date MM/DD/YY N/A N/A Result of Positive lab/ Serological Evidence Write Results here: 2-step Mantoux (PPD) 1 st Step Date Placed: Date Read: Negative Positive 2 nd Step Placed: Read: Negative Positive **MMR Vaccination 1) 2) OR Measles 1) Mumps 2) Rubella 3) OR Write Titer Result Here: OR Write Titer Result Here: OR Write Titer Result Here: ***Varicella Vaccination Please write date or Titer result 1) OR Write Titer Result Here: DTaP (within 10 years) 1) Polio (around 6 years old) Recommended: Hepatitis B 1) 2) 3) Please see next page if you do not want to obtain the Hep B vaccine. ** MMR Requirement: two vaccination dates (one must be after 1980) If not vaccinated post 1980, then current year vaccination required OR documented positive titer. *** Date of Vaccine or Titer level is required for proof of immunity to varicella. 3

4 Allied Health, Emergency Services, and Nursing Hepatitis B Vaccine Delaware County Community College is recommending that all Nursing and Allied Health students be vaccinated with the Hepatitis B vaccine. This recommendation is in compliance with the recommendations for standard precautions from the Center for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA). The vaccine takes 6 months to provide adequate protection. Please check with your family physician/nurse practitioner regarding the advisability of receiving the vaccine, its complications, and dates of administration. They are required to complete and sign this form. All Students must sign below stating that he/she read and understands this information. I have read and understand this information regarding Hepatitis B vaccination. Student Signature Date Hepatitis B Waiver Please check if you do Not want the Hepatitis B Vaccine. I have chosen Not to receive the vaccine after discussion with my physician/nurse practitioner. Health Care Provider s Signature please acknowledge below: Name (print) Signature Date 4

5 DELAWARE COUNTY COMMUNITY COLLEGE STATEMENT OF COMMITMENT Medical Health Insurance Delaware County Community College and its clinical affiliates require, without exception, that every student in the nursing and allied health programs carry their own personal medical health insurance for the duration of any semester of enrollment that requires a clinical rotation. You can use your family policy (check coverage language) or purchase a temporary policy. Information is available through https://www.healthcare.gov/ or your own insurance agent. Please make sure it is current. You may be asked to show it to your instructor at any time during clinical. Failure to carry health insurance, a violation of the Contractual Agreement with the agency, will result in your withdrawal from clinical. I have read and understand the above statements. I agree that I will be continuously covered by medical health insurance whenever I participate in any clinical experience as part of my program. I also understand that I may be asked to show proof of such coverage prior to or during any clinical rotation. Medical Health Insurance Policy # Name (Please Print) Date Signature DCCC: 8/94 Rev: 5/15 5

6 Allied Health, Emergency Services, & Nursing Nursing Program Medical Requirements To the Health Care Professional: PLEASE READ Essential Skills and Functional Abilities: I have, this day, given a thorough physical examination and based on my findings, which include medical history and physical examination; I believe he/she is physically and mentally able to undertake the Nursing Program at Delaware County Community College. The student is in good health and is not in an infectious state. He/she is free of any communicable disease, can lift 50lbs, and has no known deficits that would interfere with the ability to participate in a clinical setting. ********************************************************************************* It is essential that nursing students be able to perform a number of physical activities in the clinical portion of the program. At a minimum, students will be required to lift patients, stand for several hours at a time and perform bending activities. Students who have a chronic illness or condition must be maintained on current treatment and be able to implement direct patient care. The clinical nursing experience also places students under considerable mental and emotional stress as they undertake responsibilities and duties impacting patients lives. Students must be able to demonstrate rational and appropriate behavior under stressful conditions. Individuals should give careful consideration to the mental and physical demands of the program prior to making application. Does the student have any limitations that will interfere with patient safety? YES or NO If yes, please explain: Healthcare Provider OFFICE STAMP Health Care Provider s Signature: Licensed Healthcare Provider (M.D., D.O., N.P., P.A.) Print Name and Credentials Address and Telephone Number: 6

7 ALLIED HEALTH, EMERGENCY SERVICES & NURSING PRE-ENTRANCE MEDICAL RECORD ASSISTANCE The Wellness Center has developed access to lower cost health services to help you meet the requirements of the Allied Health, Emergency Services, and Nursing Program. Eastside Health and Dental Center * 125 E. 9 th Street Chester, PA Medical Phone: Dental Phone: Center for Family Health at Upper Darby * 5 S. State Road Upper Darby, PA Phone: Center for Family Health & Dental Center * 2600 W. 9 th Street Chester, PA Medical Phone: Dental Phone: Located in Crozer Community Hospital Family Health Center at Coatesville * 744 E. Lincoln Highway Suite 110 Coatesville, PA Phone: Located in Brandywine Center The St. Agnes Nurses Center and Day Room 233 W. Gay Street West Chester, PA (behind the Church in Lawrence Kelly Hall ) Phone: Must have appointment. Call Wednesday between 4 pm and 6 pm or Saturday between 10 am to noon. Where to get Vaccinations Free or low cost Administration * 2600 W. 9 th Street 2 North Chester, PA Phone: Fax: Delaware County Health Center 5 th & Penn Streets, Chester, PA Immunization clinic is held on Tuesdays. Call for an appointment: Government Services Center 601 Westtown Road, West Chester, PA Please call for current clinic schedule , extension 6453 * You will need Photo ID and, if working, your last two pay stubs. Call to find out what the cost will be. It is based on your income. Cost is higher if you do not provide proper ID and income verification. If there are children in household, you will need additional paperwork. Call Center for information. 7

8 Any Lab Test Now! Springfield Shopping Center Route 1 and 320 Springfield, PA Phone: This Company does not accept insurance, but has provided lower cost testing for our students. You must bring student ID to qualify. Total = $145 For all tests. Individual tests are discounted also. Crozer Keystone Health System Services can be obtained at two Delaware County locations: 1. Park Care Occupational Health at Taylor Hospital 8 Morton Ave, Suite 206 Taylor Hospital Medical Office Building (located across driveway from ER entrance) Ridley Park, PA To schedule an appointment, call: (Hours: Monday-Friday 8 am-5 pm) Or 2. Springfield Hospital at the Healthplex 196 W. Sproul Rd, Suite 110 (located directly across entrance to Healthplex) Springfield, PA To schedule an appointment, call: (Hours: Monday-Friday 8 am-5 pm) If your health insurance approves coverage for these tests, on your request, you will be provided with a lab numbered coded receipt which you can submit to your insurance company for reimbursement. Cost for all tests is $165. You need only get the tests you need to meet requirements. Cost breakdown is as follows: CBC $14 Measles Titer $20 RPR Serology $20 Rubella Titer $20 Drug Screen $46 Varicella Titer $20 Mumps Titer $25 This information is subject to change. IT IS YOUR RESPONSIBILITY TO VERIFY ACCURACY WITH CLINIC OR LABORATORY PRIOR TO YOUR SERVICE DATE. DCCC: 2/01 Rev: shared/health forms folder/health Form Feb/2015 & DISCSER2015 8

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