Dear Nurse Refresher Student,

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1 Dear Nurse Refresher Student, Congratulations on your registration into the RN-LPN Nurse Refresher LifeLong Learning Health Care Program! In preparation for your clinical experience there are some items that need your immediate attention. As a clinical student, it is your responsibility to maintain current health records while in a healthcare program. For admission to all clinical agencies, students must have a copy of all enclosed documents on file in the LifeLong Learning Office. Give all completed forms to your instructor on the first day of class, students who do not have required documentation will not be allowed at the clinical site. Personal Documentation & Health Requirements 1. Documentation of current license. LifeLong Learning staff will verify the license is active by referencing the State of Michigan online license verification system: If there is an infraction upon your license you must provide Michigan Board of Nursing approval documentation to the LifeLong Learning department prior to beginning of class. 2. Physical Examination Delta College Physical Exam Form take to your personal physician to complete and give to your instructor on the first day of class. It is suggested that you call your physician immediately as it may take 4-6 weeks to make an appointment. 3. Hepatitis B Vaccine Hepatitis B Acknowledgement/ Release Form 4. Signed Health & Wellness Waiver and Release Form 5. Signed Release for Training and Participation Form 6. Documentation of Negative TB Skin Test a positive skin test requires annual documentation by a physician or by a chest x-ray every two years. 7. Documentation of MMR (measles, mumps, rubella) immunization documentation unless you were born before 1957 you may request a rubella titer drawn by your physician if no documentation is present. 8. Documentation of Td (tetanus) immunization documentation, current within 10 years 9. Documentation of Varicella vaccination or documentation of diagnosis or verification of disease (Chicken Pox or Shingles) 10. Influenza vaccination required annually 11. CPR Card (Red Cross -CPR for the Professional Rescuer or American Heart Association Health Care Provider) Current Criminal History In accordance with Public Act 303 of 2002, section 20173; if your criminal history includes an instance that will prohibit you from participating as a student in the clinical experience, you will be dropped from the program and no refund will be given. If your background includes criminal history which would prohibit you from working in a healthcare facility, you are advised to drop the program prior to the first day of class. 12. Signed Current Criminal History Release Form The State of Michigan has mandated that we do LiveScan fingerprinting. We do not accept fingerprinting from other agencies. The cost to students for LiveScan is $ Students must go to the Delta College Bookstore and tell them you are there to pay for fingerprinting for the Nurse Refresher Program. The Bookstore will then give you a receipt/voucher for payment. Please make checks payable to Delta College.

2 You must schedule your fingerprinting with the Public Safety Office in N102. Simply present your completed Delta College LiveScan Fingerprint Request Form and your receipt/voucher (obtained from the Bookstore) to the Public Safety Officer, and then schedule your fingerprinting appointment. 13. Signed Delta College Live Scan Fingerprint Request Form Delta College ID card. Prior to the 1 st day of class you will need to get a Delta College student ID card, available in the Public Safety Office in the N-wing. Items to bring with you are a valid picture id along with your printed statement of registration in the Nurse Refresher program. This service is free of charge and will be used to create clinical badges. Please complete the attached materials and bring them with you on your first day of class, if there is any missing documentation you will not be allowed on the clinical site. Any questions regarding these health forms will be addressed by your instructor at that time. If you have any additional questions, please call the Delta College LifeLong Learning Department at Respectfully, Delta College LifeLong Learning

3 DELTA COLLEGE STUDENT PHYSICAL EXAMINATION FORM All health records submitted become property of Delta College. Students are encouraged to make copies for their own record before submitting. Only the original of this form will be accepted. Name Student Number Clinical Program Enrolled In Address Phone Emergency Contact Person/Phone PLEASE NOTE: Before placement with any clinical agency is permitted, clinical program students must submit documentation to verify the following: Current Physical Examination (using this form) Current Negative* TB Test Result (cannot be administered within 30 days of any immunizations) Hepatitis B Vaccine or Signed Waiver Measles/Mumps/Rubella (MMR) Immunizations (except those born before 1957) or Titer Tetanus/Diptheria/Acellular (Td, Tdap) vaccination (within the last 10 years) or Titer Varicella vaccination or documentation of diagnosis or verification of disease (Chicken Pox or Shingles) by a health-care provider Influenza vaccination required annually *If your skin test is positive, verification of absence of TB must be documented annually in accordance with current established protocol. STUDENT PERSONAL HEALTH HISTORY Yes No 1. Are you currently under medical care? If yes, explain. Yes No 2. Are you currently under psychological care? If yes, explain. Yes No 3. Are you currently taking any prescribed medications? If yes, explain. Yes No 4. Have you ever had a latex sensitivity reaction or are you allergic to latex? If yes, explain. Yes No 5. Are you a smoker? Authorized Provider Verification - I have reviewed and discussed the above personal health history with the student. AUTHORIZED PROVIDER SIGNATURE (Physician/Physician s Assistant/ Nurse Practitioner) DATE

4 The typical demands placed on the health career student in training, as well as on the entry-level health care provider, are listed below. Are you aware of any condition(s) that might limit this student with regards to any of these typical demands? If you are not aware of any issue mark No. Yes No STRENGTH Frequently and repetitively perform physical activities requiring ability to push/pull or lift objects of 50 pounds independently, and more than 50 pounds with assistance and to transfer objects or patients of more than 100 pounds. Yes No MANUAL DEXTERITY Consistently perform simple gross motor skills such as handshaking, writing, and typing; and complex fine motor manipulative skills such as insertion of IV lines, calibration of equipment, drawing blood, endotracheal intubation, etc. Yes No COORDINATION Consistently perform gross body coordination such as walking, filing, retrieving equipment; tasks that require eye-hand coordination such as keyboard skills, and tasks which require arm-hand steadiness such as taking B/Ps, calibrating tools and equipment, holding retractors, probing periodontal spaces, etc. Yes No MOBILITY/ENDURANCE Consistently perform mobility skills such as walking, standing, prolonged standing or sitting in an uncomfortable position; move quickly in an emergency and maneuver in small spaces; requires frequent twisting and rotating and reaching. Yes No VISUAL DISCRIMINATION Consistently see objects far away, discriminate colors, and see objects closely and peripherally as in reading faces, dials, monitors, fine small print, etc. Yes No HEARING Consistently hear normal sounds with background noise and distinguish sounds. Some examples include conversations, monitor alarms, emergency signals, breath sounds, cries for help, heart sounds, etc. Yes No CONCENTRATION Consistently concentrate on essential details even with interruptions such as client requests, IVAC s, alarms, telephones ringing, beepers, conversations, etc. Yes No ATTENTION SPAN Frequently attend to tasks/functions for periods exceeding 60 minutes in length with interruptions such as those mentioned above. Yes No CONCEPTUALIZATION Consistently understand, remember, and relate to specific and generalized ideas, concepts, and theories generated and discussed simultaneously. Yes No MEMORY Remember tasks/assignments given to self and others over both short and long periods of time as well as significant amount of patient data with interruptions and distractions. Yes No COMMUNICATION Interact non-verbally and verbally in an appropriate manner. Read and interpret written instructions of information functionally in English. Yes No MENTAL STABILITY Demonstrate a non-disruptive, positive attitude; the mental capacity to function effectively under stress and have control of his/her emotions. AUTHORIZED PROVIDER SUMMARY ASSESSMENT (Physician/Physician s Assistant/Nurse Practitioner) Considering this student s physical examination (and personal health history on other side), are there any conditions, disabilities, or limitations that could restrict the student s participation in a health career educational program or limit subsequent employability? No Yes Explain (Attach a separate sheet if necessary) Are there any accommodations necessary for this student? No Yes Explain Are there any special precautions, restrictions, or conditions that might result in an emergency (e.g., allergies, latex sensitivity, diabetes, seizure disorder, fainting, other) in the classroom or during clinical practice? No Yes Explain The Authorized Provider completed, conducted, reviewed and/or verified all sections of this physical exam form. AUTHORIZED PROVIDER SIGNATURE DATE PRINT AUTHORIZED PROVIDER NAME AUTHORIZED PROVIDER OFFICE PHONE Given these typical demands, are there any medical conditions, disabilities, or limitations that could restrict your participation in a health career education program, or limit subsequent employability? Yes* No I understand all of the explanations above and have been given ample opportunities to have all of my questions answered, AND, I certify that my answers on this form and all other forms are true and complete. I also understand that I may be denied acceptance into or removed from a program if any of this information has been falsified. I give Delta College permission to contact my physician and any other health care provider to seek further information pertinent to my admission, matriculation and retention in any health career education program. I give my health care providers my permission to release any and all information requested by Delta College. STUDENT SIGNATURE DATE *Attach a separate sheet and explain any accommodations necessary for you to meet the job requirements

5 Health and Wellness Programs Communicable Diseases, Hepatitis B, HIV Acknowledgement and Release Form I hereby acknowledge that I have received and reviewed the information provided regarding communicable diseases including Hepatitis B and HIV. I understand that I assume the risk of infection from communicable diseases, including Hepatitis B and HIV (AIDS) from my clinical experience. I have received information and have had my questions answered about the Hepatitis B vaccine. I understand that receiving the vaccine is highly recommended, but not required, for persons such as health care workers who have contact with blood/bloody secretions. I also understand that, should I elect to receive the Hepatitis B vaccine, it is MY RESPONSIBILITY to pay the cost of the series of three (3) injections required. I understand that all medical bills associated with contracting a communicable disease during my clinical education are my responsibility and Delta College has no obligation to pay my medical expenses. I hereby release Delta College, its employees, teaching affiliates, and members of its Board of Trustees from any and all claims and actions for personal injury or death resulting from communicable diseases contracted while a student at Delta College, whether arising out of clinical experience or otherwise. PLEASE CHECK ONE OF THE FOLLOWING: I HAVE ALREADY RECEIVED THE HEPATITIS B VACCINE AND VERIFICATION IS ATTACHED. I AM IN THE PROCESS OF GETTING THE VACCINE. I DECLINE THE HEPATITIS B VACCINE AND RELEASE DELTA COLLEGE FROM LIABILITY SHOULD I BECOME INFECTED WITH HEPATITIS B. STUDENT S NAME (PRINT) STUDENT S SIGNATURE PROGRAM DATE

6 Health and Wellness Programs Waiver and Release Form I understand that as a student in the RN-LPN Nurse Refresher Program at Delta College (the College ), in order to obtain a certificate of completion, I am required to participate in certain clinical experiences in facilities that provide direct care to patients (the Facilities ). I understand that in order for me to participate in these clinical experiences, the College and the Facilities require that I provide current health documents, including but not necessarily limited to Physical Examination, TB Test (current annual proof of results and date read), Immunization records relating to Measles, Mumps, Rubella (MMR); Tetanus (Td), and Hepatitis B (either sign waiver or attach proof of shots and dates), Varicella vaccination or diagnosis of disease, influenza vaccination and CPR Card (Red Cross/CPR for the Professional Rescuer or American Heart Association/Health Care Provider), (the Documents ). I further understand that I must be fingerprinted as part of health agency requirements. Results of the fingerprinting will be secured and held confidential, but may be shared with clinical agencies, prospective employers, the Board of Nursing and/or when requested and/or as otherwise required by law. I agree to provide multiple copies of the Documents to Delta College LifeLong Learning staff, and to provide updated copies, as requested. I understand that the College will provide the Documents to the Facilities, and I agree that it may do so. I waive any claim which I may have against the College, now or in the future, and I hereby agree to indemnify, defend, release and hold harmless the College, its employees, representatives, agents, and assigns from and against any claim, action, suit, proceeding, loss, cost, damage, liability, deficiency, fine, punitive damage or expense in connection with or arising out of possession or use of the Documents by the College or the Facilities, or the College s providing the Documents to the Facilities. I have read and understand the foregoing statements and I agree to the terms. Student Legal Signature Student Legal name (Type or Print) Witness Signature Witness Legal name (Type or Print) Date

7 Release for Training and Participation I, the undersigned student of Delta College, understand and acknowledge that as part of the instruction that I am to receive as part of the LifeLong Learning RN-LPN Nurse Refresher Program I may participate, voluntarily in invasive procedures. These activities will require me to be a participant and a receiver of these procedures. These invasive procedures will be under the supervision of an instructor. Indicate the following invasive procedures you are willing to participate in by initialing before the procedure: capillary blood glucose monitoring, IV starts, venipuncture, injections of saline (subcutaneous, intradermal, intramuscular) and nasogastric tube insertion. Any additional invasive procedures must be agreed to by the student and noted on this release form. The student must add the procedure and initial to indicate their agreement. Additional skill(s): I understand and acknowledge that these activities might, under some circumstances about which I have been advised, pose certain dangers, including, but not limited to, the exposure to such diseases as HIV and hepatitis and therefore, involve the risk of serious injury and death. In consideration of my opportunity to participate in this instruction, I hereby release Delta College, its elected and appointed officials, employees, students, peers, agents and volunteers from any and all liability, claims, demands, actions or causes of action arising out of any damage, loss or injury to my person or my property or resulting in my death, while enrolled in the LifeLong Learning RN-LPN Nurse Refresher Program. I hereby assume full responsibility for and risk of bodily injury, death or property damage that I suffer while enrolled in the LifeLong Learning RN-LPN Refresher Program and participating in the activities contemplated by this release. I have read and voluntarily sign the release and waiver of liability. Signed this day of, 20. Student Signature Witness I choose not to have invasive procedures performed on me that are part of the LifeLong Learning RN-LPN Nurse Refresher Program and to notify all of my instructors of my intent not to participate in invasive procedures. I understand that I may practice these procedures on simulation models. This, however, does not relieve me of my responsibility to perform these procedures competently as a student in the clinical setting. Student Signature Witness

8 Delta College LIVE SCAN FINGERPRINT REQUEST FORM APPLICANT INFORMATION: (Reason for Fingerprints): RN/LPN Refresher Program (LifeLong Learning) Applicant Name Last First Middle Aliases (AKA) Place of Birth (State) Date of Birth Student Number Drivers License State Drivers License Number Applicant Address Street City State Zip Code Gender Race Height Weight Hair Color Eye Color Scars, Marks, Tattoos *Purchase LiveScan fingerprinting voucher from Delta College Bookstore at cost of $75.00

9 Background Checks/Criminal History In addition to the LiveScan fingerprinting, a Criminal Background Check (CBC) will be completed on all RN/LPN Refresher students as part of health care agency requirements. A release form for the Delta College Public Safety unit will need to be signed on the first day of class. Results of the Criminal Background check will be kept confidential. If results indicate a felony/misdemeanor conviction, the program manager will discuss the findings and the process with the student. Note: A felony/misdemeanor conviction may prohibit the student from participating in the clinical experience and student may be dropped from the program with no refund given. If your background includes criminal history which would prohibit you from working in a healthcare facility, you are advised to drop the program prior to the first day of class. Public Act 303 of 2002, Section (1) requires that a health facility or agency that is a nursing home, county medical care facility, or home for the aged shall not employ, independently contract with, or grant clinical privileges to an individual who regularly provides direct services to patients or residents in health facilities or agency if the individual has been convicted of one or more of the following: (a) A felony or an attempt or conspiracy to commit a felony within the 15 years immediately preceding the date of application for employment or clinical privileges or the date of the execution of the independent contract. (b) A misdemeanor involving abuse, neglect, assault, battery, or criminal sexual conduct or involving fraud or theft against a vulnerable adult as that term is defined in the section 145m of the Michigan penal code, 1931 PA 328, MCL m, or a state or federal crime that is substantially similar to a misdemeanor described in this subdivision, within 10 years immediately preceding the date of application for employment or clinical privileges or the date of execution of the independent contract. The Michigan Penal Code defines a vulnerable adult as one or more of the following: (i) An individual age 18 or over who, because of age, developmental disability, mental illness, or physical disability requires supervision or personal care or lacks the personal and social skills required to live independently. (ii) An adult as defined in section 3(1) (b) of the adult foster care-licensing act, MCL (iii) An adult as defined in the section 11(b) of the social security welfare act, MCL Public Act 303, Subsection 11 As a condition of continued employment all individuals involved with covered entities under this new law will be required to agree in writing to immediately report the fact that they have been arrested for or convicted of one (1) or more of the criminal offenses listed in subsection (1)(a) and (b). Students should also be aware that the current licensure application form now requests the following information: a) History of felony conviction(s) b) History of conviction of a misdemeanor punishable by imprisonment for a maximum of two years. c) History of conviction of a misdemeanor involving illegal delivery, possession or use of alcohol or a controlled substance (including motor vehicle violations). d) Treatment of substance abuse in past two years e) History of malpractice settlements, awards or judgments. f) Previous application for licensure/or NCLEX in Michigan or other jurisdictions. g) History of revoked, suspended, or denied licensure or registration, or other disciplinary action taken or presently pending. Questions may be directed to the Michigan Board of Nursing ( )

10 CURRENT CRIMINAL HISTORY RELEASE I hereby voluntarily agree to permit the Delta College Department of Public Safety access to all information on file concerning my conviction record, if any, present or past, in accordance with Public Act 303 of 2002, Section (see attached), as a condition of Delta College s LifeLong Learning requirements and/or scholarship opportunities. As a condition of continued enrollment in the RN/LPN Nurse Refresher program, I agree to report, immediately, in writing, upon being convicted of one or more of the criminal offenses covered by this law. I understand that if my criminal history includes an instance that will prohibit me from participating as a student in the clinical experience, I will be dropped from the program and no refund will be given. If my background includes criminal history which would prohibit me from working in a healthcare facility, I acknowledge that I have been advised to drop from the RN/LPN Nurse Refresher program prior to the first day of class. Results of the background check will be secured and held confidential, but may be shared with clinical agencies, prospective employers, and/or when requested and/or as otherwise required by law. NAME: RACE: Last First Middle Initial SEX: DATE OF BIRTH: Month Day Year MICHIGAN DRIVER LICENSE #: OTHER NAMES: Last First Middle Initial Last First Middle Initial SIGNATURE: (Applicant s Name) DATE

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