HEALTH CLEARANCE (HC) POLICY & REQUIREMENTS POLICY:

NYUCN Baccalaureate Program STUDENT HEALTH CLEARANCE (HC) POLICY & REQUIREMENTS POLICY: All students participating in clinical learning experiences at the NYU College of Nursing (NYUCN) must be in compliance with health clearance policies as required by New York University and the NYUCN. The student is responsible for providing NYU with evidence of immunity and health status. Students requesting a reasonable accommodation must register with the Moses Center, located at 726 Broadway, 2nd floor. Students are also required to make two copies of the original Health Clearance documents and: 1. Keep a copy of the Health Clearance (HC) documents during tenure at NYUCN 2. Scan and email, fax, hand deliver, or mail a copy of the completed and signed HC documents to: NYU College of Nursing 726 Broadway, 10th Floor, Room 1090 Fax: 212-995-4351 Phone: 212-992-9415 Email: nursing.healthclearance@nyu.edu If unavailable, a copy of the completed and signed Health Clearance documents may be left in the Clinical Affairs Office mailbox located on the 10th floor of 726 Broadway. PURPOSE OF POLICY: NYUCN students have clinical learning experiences and are placed in direct contact with patients. This contact places students at risk for both exposure to and transmission of communicable diseases and blood-borne pathogens. Therefore, specific procedures are needed to (1) decrease health risks to students, (2) protect patients and other health care professionals with whom students interact, and (3) comply with NYUCN healthcare agency contracts, New York University Student Health Center policies, OSHA regulations, and New York State Department of Health policies. Note: Health clearance is required for any course that includes a clinical experience. Health clearance must be met no later than six (6) weeks prior to the first day of the clinical course or participation will be prohibited. HEALTH CLEARANCE REQUIREMENTS: Carefully review the requirements below to successfully complete the attached Health Clearance Packet in its entirety. Please note that the NYUCN Health Clearance Requirements are different from the NYU Student Health Center requirements. Information on the NYU Student Health Center is available at www.nyu.edu. The NYU Student Health Center s Meningococcal Meningitis response form is also attached at the end of this packet. A. Required Every Year (every 12 months based on the date tests are performed): FORM A 1. History & Physical (H&P): Students must have a History and Physical performed yearly by a health care provider (physician or nurse practitioner). The date of the examination must be indicated on FORM A. 2. PPD (Mantoux) or QuantiFERON-TB Gold (blood test): Students must have a PPD or QuantiFERON-TB Gold test performed yearly (in some cases every 6 months). The date the PPD test was administered & the date the test was determined negative or positive must be indicated on FORM A. If a QuantiFERON-TB test is performed, the laboratory report and test results must be submitted. A positive PPD or QuantiFERON-TB test requires a one-time only post-positive chest x-ray report. An abnormal chest x-ray requires documentation of medication regimen and yearly documentation of a TB symptom check. Page 1 of 8

B. Required One Time Only: FORM B 1. Measles, Mumps, and Rubella All students must demonstrate immunity to Measles, Mumps and Rubella with proof of positive IgG titers (a laboratory blood test for the antibodies) against Measles, Mumps, and Rubella. Evidence of immunity is demonstrated with the titer value and indication of + or immune on FORM B. Negative or Equivocal MMR Titers require the student to receive one (1) MMR booster vaccine & provide proof of childhood vaccination history. All students must submit copies of laboratory reports with titer results. 2. Varicella All students must demonstrate immunity to Varicella (Chicken Pox) with proof of positive IgG titers (a laboratory blood test for the antibodies) against Varicella. Evidence of immunity is demonstrated with the titer value and indication of + or immune on FORM B. Negative or Equivocal Varicella Titer requires the student to receive two (2) doses of Varicella vaccine spaced four (4) weeks apart. All students must submit copies of laboratory reports with titer results. 3. Tetanus /Diptheria/Pertussis Vaccine (DTaP) All students must present evidence of the date of vaccination for Tetanus/Diphtheria/Pertussis (DTaP) within the last 10 years. If no documentation is presented, the student must receive a DTaP vaccine. 4. Hepatitis B (HBV) All students must demonstrate immunity to Hepatitis B with proof of a positive HBsAb titers against Hepatitis B OR provide documentation of 3-dose series of the Hepatitis B vaccine. Evidence of immunity is demonstrated with the actual titer value and indication of + or immune on FORM B OR the exact immunization dates of three (3) doses of Hepatitis B vaccine spaced over a six (6) month period (Center for Disease Control [CDC], 2001). Non-immune laboratory results require the student to receive three (3) doses of Hepatitis B vaccine spaced over a six (6) month period. If a student decides to waive the Hepatitis B vaccination, the student must sign FORM D documenting that he/she understands the possible risks associated with acquiring Hepatitis B. C. Required Every Flu Season: FORM C 1. Flu Vaccine: As per the New York State Department of Health, the flu vaccine is required during flu season (September through May). All students must complete FORM C in its entirety. D. CPR/Basic Life Support Certification for Healthcare Providers: Students are required to submit a copy of CPR/BLS Certification for Healthcare Providers. Visit the following site for information on CPR/BLS certification offered for BS students: www.nursing.nyu.edu. E. Technical Standards: Students must read and sign the last page of the attached Technical Standards. Page 2 of 8

In Case of Clinical Absence due to Medical Condition: 1. Students who are unable to attend clinical due to a medical condition: for hospitalization or for any other physical or mental illness that renders the student contagious and/or incapable of performing clinical responsibilities, must submit health clearance authorization from the appropriate clinical specialist (Nurse Practitioner or Physician) who was rendering treatment. Health Clearance must be submitted to the Office of Clinical Affairs prior to returning to a clinical area to complete a rotation. 2. After a student is cleared by the NYUCN, the student must contact the Course Coordinator to review the NYUCN BS Program s on-campus and/or off-campus clinical make-up policy. Additional Credentialing Requirements: 1. NOTE: certain health care agencies/clinical sites may require additional documentation and/or training (i.e. background check, state child abuse registry certification, HIPAA training, drug testing). If additional documentation is required, the will contact students on an individual basis. BS CLINICAL COURSES REQUIRING HEALTH CLEARANCE: Baccalaureate Program NURSE-UN.240 NURSE-UN.241 NURSE-UN.1241 NURSE-UN.1242 NURSE-UN.1243 NURSE-UN.1255 NURSE-UN.1244 NURSE-UN.1245 Adult and Elder I Nursing Acute Care Psychiatric Nursing Adult and Elder II Nursing Maternity Nursing Adult and Elder III Nursing Pediatric Nursing Community Health Nursing Leadership and Management Page 3 of 8

Health Clearance Checklist Students are responsible for maintaining up-to-date Health Clearance (HC) documentation for the entire academic year. If HC information expires during the course of the academic year, students are responsible for submitting updated Health Clearance to the NYUCN. Students are responsible for submitting all required paperwork to the NYU Health Center and NYUCN Office of Clinical Affairs at least 6 weeks prior to the start of clinical courses, and/or at the time student s HC information expires. Failure to submit the proper HC may result in a delay in starting clinical rotations or de-enrollment. A. FORM A: Required Every Year (12 months) History & Physical (H&P) PPD (Mantoux) or QuantiFERON-TB Gold (blood test) o QuantiFERON-TB Gold laboratory report attached o If positive, copy of Chest X-Ray report attached (one-time only requirement) B. FORM B: Required One-time Only Measles, Mumps, and Rubella IgG titer values indicated by HC Provider, lab report attached Varicella Titer IgG titer values indicated by HC Provider, lab report attached Hepatitis B indication of HBsAb titer values or Positive(+) Titer/Immunity by HC Provider, or verification that the series of inoculations/immunizations has been completed, or signed waiver indicating declination of vaccine or vaccine series in progress (Form D) Tetanus/Diphtheria/Pertussis Vaccine (DTaP) exact date of vaccination within the last 10 years C. FORM C: Required during Flu Season (September through May) (may be obtained at NYU Student Health Center once the academic year begins) D. CPR/Basic Life Support Certification for Healthcare Providers E. Technical Standards: Read Technical Standards, sign last page and submit with health clearance *** NYU Student Health Center Meningococcal Meningitis Vaccination Response Form completed and signed Health Clearance may be scanned and emailed, faxed, hand delivered, or mailed to: NYU College of Nursing 726 Broadway, 10th Floor, Room 1090 Fax: 212-995-4351 Phone: 212-992-9415 Email: nursing.healthclearance@nyu.edu If unavailable, a copy of the completed and signed Health Clearance documents may be left in the Clinical Affairs Office mailbox located on the 10th floor of 726 Broadway. **KEEP A COPY OF ALL DOCUMENTS FOR YOUR RECORDS** Page 4 of 8

Current Clinical Course(s): To be completed by student: FORM A Semester & Year: Program: BS MS DNP Name (Print): Date of Birth: Phone #: (first, mi., last) (mm/dd/yyyy) NYU N Number: Email: NXXXXXXXX I understand that the agency to which I am assigned may require more health data than listed below. I hereby authorize New York University to release my health clearance information on this form and all associated documents, including laboratory reports and immunization waivers, to any health care provider, which may require it in connection with my participation in a clinical course. I also understand that it is my responsibility to update FORM A annually. I agree that if I become ill, have a surgical procedure and/or become hospitalized, develop a condition, or have an exacerbation of a condition that limits my ability to fulfill the NYUCN Program requirements, I will obtain health clearance again from a health care provider before returning to the Program. I have brought the original of the required completed/signed HC documents to: 1) a copy to, NYUCN, 726 Broadway, 10 th Floor, Room 1090 & 2) kept an additional copy for my own records. Student Signature Date To be completed by a Certified Nurse Practitioner or Physician: An examination was performed on the above named individual. The following assessments were included: 1. Complete history and physical (H&P) examination Date of Exam: mm/dd/yyyy 2. TB Screening: PPD (Mantoux) Date Administered: Date Read: mm/dd/yyyy Negative QuantiFERON-TB Gold Date Reported: mm/dd/yyyy (lab report must be attached) PPD or QuantiFERON Determination Positive (if positive, chest x-ray report is a one-time only requirement) Chest x-ray has been documented post-positive result? Copy attached Normal Chest x-ray mm/dd/yyyy Abnormal Chest x-ray Patient was/is treated with prophylactic medication. Date treatment started: / / Symptom Check for one (1) year post-positive PPD with annual H&P By signing below, the Health Care Provider (Nurse Practitioner or Physician) has determined that the named individual is eligible for clinical practice and agrees with the following statement: I find him/her to be in good physical and mental health; he/she is free from any health impairment which is of potential risk to patients, personnel, students, or faculty and which might interfere with the performance of his/her nursing student responsibilities, with or without a reasonable accommodation, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances that may alter the individual s behavior has been considered in this evaluation. If a reasonable accommodation is required, I have identified the accommodation and the basis of the accommodation on a separate attachment. NOTE: THIS FORM SHOULD NOT BE SIGNED UNLESS THE INDIVIDUAL IS ABLE TO PARTICIPATE FULLY IN NURSING PRACTICE. Date Signature of Nurse Practitioner or Physician Address: Print or Type Name Tel. No: Page 5 of 8

Current Clinical Course(s): To be completed by student: FORM B Semester & Year: Program: BS MS DNP Name (Print): Date of Birth: Phone #: (first, mi., last) NYU N Number: Email: (mm/dd/yyyy) NXXXXXXXX I understand that the agency to which I am assigned may require more health data than listed below. I hereby authorize New York University to release my health clearance information on this form and all associated documents, including laboratory reports and immunization waivers, to any health care provider, which may require it in connection with my participation in a clinical course. I also understand that it is my responsibility to update FORM A annually. I agree that if I become ill, have a surgical procedure and/or become hospitalized, develop a condition, or have an exacerbation of a condition that limits my ability to fulfill the NYUCN Program requirements, I will obtain health clearance again from a health care provider before returning to the Program. I have brought the original of the required completed/signed HC documents to: 1) a copy to, NYUCN, 726 Broadway, 10 th Floor, Room 1090 & 2) kept an additional copy for my own records. Student Signature Date Students Must Submit Titer Results & All Laboratory Reports Must be Attached Measles (Rubeola) Titer: Date Drawn IgG Titer Value Positive Negative Revaccination Date: (If Titer is Negative or Equivocal) Mumps Titer: Date Drawn IgG Titer Value Positive Revaccination Date: Negative (If Titer is Negative or Equivocal) Rubella Titer: Date Drawn IgG Titer Value Positive Revaccination Date: Negative (If Titer is Negative or Equivocal) Varicella Titer: Date Drawn IgG Titer Value Positive Revaccination #1 Date: Negative Revaccination #2 Date: *Past Titer Results are Acceptable. Titers do not need to be repeated. (If Titer is Negative or Equivocal) **Required: Vaccination History Must be Attached in the case of Negative Titers Hepatitis B: Dates of Vaccinations: # 1 # 2 # 3 OR (HBsAb) Titer: Date Drawn Numerical Value Positive OR Negative Signed Waiver: FORM D Tetanus/Diptheria/Pertussis Vaccine (DTaP) has been administered within ten (10) years Yes Date No DTap administration is required. Date Administered Signature of Nurse Practitioner or Physician Print or Type Name Date Address: Tel. No: Page 6 of 8

Current Clinical Course(s): Semester & Year: Program: BS MS DNP FORM C Seasonal Flu Vaccination Documentation Mandatory During Flu Season (September through May) Please complete all data requested below Name of Student: (first, mi., last) Date of Birth: (mm/dd/yyyy) Date of Vaccine Administration: (mm/dd/yyyy) Manufacturer: Lot: Dose: Person Administering (Name and Title): Signature of Person Administering: License #: Address: Completed Flu Vaccination Documentation may be scanned and emailed, faxed, hand delivered, or mailed to: NYU College of Nursing 726 Broadway, 10th Floor, Room 1090 Fax: 212-995-4351 Phone: 212-992-9415 Email: nursing.healthclearance@nyu.edu If unavailable, a copy of the completed and signed Health Clearance documents may be left in the Clinical Affairs Office mailbox located on the 10th floor of 726 Broadway. Page 7 of 8

Current Clinical Course(s): Semester & Year: Program: BS MS DNP FORM D Hepatitis B Vaccine Waiver (if vaccine is waived, submit one-time only) I understand that during my clinical learning experiences I may be exposed to blood or other potentially infectious materials, and I may be at risk of acquiring hepatitis B virus (HBV) infection, a serious disease. I have been given the opportunity to be vaccinated with hepatitis B vaccine. I am aware of the risks associated with acquiring Hepatitis B. Please check the appropriate statement: I decline hepatitis B vaccination at this time. I have been informed and understand the possible risks of acquiring hepatitis B. I am currently in the process of receiving the 3-dose series of hepatitis B vaccine at 0-, 1-, and 6-month intervals. I will obtain anti-hb serologic testing 1-2 months after dose #3. Until this process is completed, I have been informed and understand that I continue to be at risk of acquiring hepatitis B. Student Signature Print or Type Name NYU N Number Date: Adapted from Occupational Safety & Health Administration US. Department of Labor Standard Number: 1910.1030 App A Can be waived; If a student has waived the Hepatitis B vaccination, the student indicates that he/she is aware of the risks of not receiving the Hepatitis B vaccination. Female students who believe they are pregnant must provide a letter from their health care provider indicating their expected delivery date and the lab result for Anti-Hepatitis B; although Hepatitis B vaccine is not contraindicated during pregnancy, the decision to receive the vaccination should be made in consultation with one s health care provider. Students are advised that some health care/clinical agencies will not allow anyone who has not received the Hepatitis B vaccination, and/or demonstrated immunity to Hepatitis B, to participate in a clinical rotation at their site. Page 8 of 8

THE NEW YORK UNIVERSITY COLLEGE OF NURSING TECHNICAL STANDARDS FOR CORE PROFESSIONAL NURSING COMPETENCY PERFORMANCE: 3/27/13 New York University College of Nursing ( NYUCN ) is committed to producing lifelong learners who will excel in their careers and be recognized as leaders in providing patient-centered nursing care. NYUCN programs strive to educate outstanding healthcare providers to care for patients with broadly-based knowledge, critical judgment, and well-honed nursing competencies that include core professional knowledge, attitudes and technical nursing skills appropriate to the respective program outcomes ( BS, MS, Post-MS Advanced Certificate, DNP, and PhD). The NYUCN Technical Standards for Core Professional Nursing Competency Performance ( Technical Standards ) (web link) are an integral component of NYUCN academic requirements that identify core professional nursing competencies in five specific domains -- Communication, Observation, Cognitive, Motor, and Behavioral and Social Attributes. Nursing students must meet all the requirements of the Technical Standards, with or without reasonable accommodations, in order to successfully progress through and graduate from their respective curricula. Individuals interested in applying for admission to NYUCN are encouraged to review the Technical Standards to become familiar with the skills, abilities, and behavioral characteristics required to complete the programs. All NYUCN students must review the Technical Standards, sign the acknowledgment on the last page, and return this document to NYUCN, 726 Broadway, 10 th Floor. Reasonable Accommodations for Qualified Individuals with Disabilities NYUCN is committed to providing educational opportunities to otherwise qualified students with disabilities to afford such students an opportunity equal to that provided to non-disabled students to achieve a desired educational outcome. A qualified individual with a disability is one who, with or without reasonable accommodations, meets NYUCN s academic requirements and Technical Standards. Students with disabilities are not required to disclose their disability to NYUCN. However, students wishing to request reasonable accommodations must register with NYU s Henry and Lucy Moses Center for Students with Disabilities (CSD) to initiate the process. Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act define a person with a disability as someone who: (1) has a physical or mental impairment that substantially limits one or more major life activities; OR (2) has a record of such an impairment; OR (3) is regarded as having such an impairment. Students are encouraged to meet with a CSD representative when unsure if a condition qualifies as a disability. CSD determines qualified disability status and assists students in obtaining appropriate accommodations and services. Decisions regarding reasonable accommodation are determined on a case by case basis taking into consideration each student s disability-related needs, disability 3_27_13 Final Page 1 of 5

documentation and program requirements. While the process for requesting reasonable accommodations may be started at any time, reasonable accommodations may not be implemented retroactively. It therefore is important that students allow ample time for their accommodation requests to be processed. While NYUCN will make every effort to work with students with disabilities to accommodate their disability-related needs, NYUCN is not required to provide accommodations that fundamentally alter or waive essential program requirements. Students should review the information found on the CSD web-site (http://www.nyu.edu/life/safety-health-andwellness/students-with-disabilities.html) or contact the CSD directly at: Henry and Lucy Moses Center for Students with Disabilities, 726 Broadway, 2nd Floor,, Phone: 212-998-4980, Fax: 212-995-4114, email: mosescsd@nyu.edu. TECHNICAL STANDARDS COMPETENCY DOMAINS I. COMMUNICATION Competencies: The Technical Standards include the ability to communicate effectively with a wide variety of individuals. Rationale: communication competencies include knowledge, attitude, and skills necessary to provide quality and safe patient care in all health care settings. Examples of communication competencies include, without limitation, the ability to: communicate clearly in English (or to a patient language interpreter if the patient and/or family members/significant others do not speak English) in a professional and sensitive manner with patients and their family members/significant others, health team members, faculty, and peers of diverse ethnic, religious, and cultural backgrounds in professional nursing practice settings as well as in the academic setting. accurately elicit information from patients, family member/significant others, health team members, and/or faculty related to a patient s medical history and current status necessary to adequately and effectively evaluate a patient s condition. use and comprehend standard professional nursing and medical terminology when using and/or documenting a patient s print or electronic health record. convey appropriate information to patients and the health care team and teach, direct and counsel a wide variety of individuals, including explaining treatment procedures and initiating health education. II. OBSERVATION Competencies: The Technical Standards include the ability to make observations in connection with other identified professional nursing student competencies. Rationale: Nursing student observation competencies include the knowledge, attitude, and skills necessary to provide quality and safe patient care to patients in all health care settings. Examples of observation competencies include, without limitation, the ability to: 3_27_13 Final Page 2 of 5

use and accurately interpret information obtained from digital, analog, and waveform diagnostic tools (e.g., sphygmomanometer, otoscope, stethoscope, ophthalmoscope, EKG, IVs) and other diagnostic tools that monitor or obtain physiological phenomena. accurately observe a patient during the course of a comprehensive or focused physical assessment to determine signs and symptoms of disease, pain, and infection. accurately observe and interpret a patient s heart and body sounds, body language, color of wounds, drainage, urine, feces, expectoration, and sensitivity to heat, cold, pain, and pressure. III. COGNITIVE Competencies: The Technical Standards include the ability to demonstrate cognitive abilities in connection with the other identified professional nursing student competencies. Rationale: Nursing student cognitive competencies include demonstrating the knowledge, attitude, and skills necessary to provide quality and safe patient care to patients in all health care settings. Examples of cognitive competencies include, without limitation, the ability to: demonstrate cognitive abilities related to course and program outcomes, which include intellectual, conceptual, integrative, quantitative, critical thinking, and comprehension skills that indicate that the student is able to carry out the nursing process in the care of patients. measure, calculate, reason, analyze, and synthesize subjective and objective data to carry out the nursing process in relation to patient assessment, diagnosis, goals, plan of care/interventions, and evaluation. retrieve and critically appraise patient related research to determine the best available research evidence (quantity and quality) to use in a patient s nursing plan of care. comprehend extensive information from written documents, visual and/or oral presentations, and patient computer information systems in order to carry out the nursing process. analyze and prioritize all aspects of patient care in a prompt and timely fashion. synthesize objective and subjective findings and diagnostic studies in order to formulate nursing diagnoses. use synthesized data to initiate a nursing plan of care which appropriately integrates patient preferences in order to provide appropriate, quality, and safe patient care. accurately follow course syllabi, assignment directions, patient protocols, and any action plan(s) developed by deans, faculty, administrators, or health care agency staff. IV. MOTOR Competencies: The Technical Standards include the ability to perform or assist with nursing interventions to provide comprehensive general nursing care and treatment in connection with other identified professional nursing student competencies. Rationale: Nursing student motor competencies include the knowledge, attitude, and skills necessary to provide quality and safe patient care to patients in all health care settings. Examples motor competencies include, without limitation, the ability to: obtain accurate information from patients using gross and fine motor skills appropriate to the technique (e.g., palpation, auscultation, and percussion) and common medical/nursing Page 3 of 5 3_27_13 Final

digital, analog, and waveform diagnostic tools and equipment (e.g., sphygmomanometer, otoscope, stethoscope, ophthalmoscope, EKG, IVs) that monitor or obtain physiological phenomena or data. perform and/or assist with expected nursing student procedures, treatments, and medication administration using sterile or clean techniques appropriate to the type of procedure, treatment or medication administration (e.g., drawing medications into syringes in precise measurements; giving a medication IV, IM, or subcutaneously using the appropriate syringe or apparatus; performing tracheotomy care and suctioning; inserting urinary catheters; creating sterile fields; sterile and clean dressing changes) and administering basic life support (BLS) cardiopulmonary resuscitation or advanced cardiopulmonary life support (ACLS), depending upon the nursing student s program level. appropriately move, transfer, and position patients or equipment under a variety of circumstances with or without a lift team or assistive devices during the delivery of general nursing care or in emergency situations. have the endurance to complete all required tasks during the assigned period of clinical practice in order to carry out the nursing process in the context of patient care delivery. navigate patients rooms, work spaces, and treatment areas with appropriate precision and speed to carry out the nursing process during the delivery of general nursing care or in emergency situations. V. BEHAVIORAL AND SOCIAL ATTRIBUTES Competencies: The Technical Standards include the ability demonstrate behavioral and social attributes in academic and in on-campus clinical and off-campus clinical settings in connection with other identified professional nursing student competencies included in the AACN s Essentials of Baccalaureate, Master s and Doctoral Education for Professional Nursing Practice, the National Student Nurses Association, Inc. Code of Ethics: Part II Code of Academic and Clinical Conduct and Interpretive Statements, and NYU/NYUCN s student academic integrity policy. Rationale: Nursing student behavioral and social attributes competencies include the knowledge, attitude, and skills necessary to provide quality and safe patient care in all health care settings. Examples of behavioral and social attributes competencies include, without limitation, the ability to: communicate in a mature, professional, culturally sensitive, therapeutic, accurate and effective manner with patients, patients family members/significant others, members of the health care team, faculty, staff, and peers. maintain effective, appropriate, and sensitive relationships with patients, patients family members/significant others, peers, faculty, staff, and other health care professionals. uphold professional nursing standards, including punctual attendance at on-campus clinical simulation and off-campus clinical settings. conform to NYUCN s clinical dress code and requirements of all clinical settings. work cooperatively and with honesty and integrity with peers, faculty, and members of the healthcare team. Page 4 of 5 3_27_13 Final

adapt to changing environments and exhibit flexibility and composure in the face of uncertainties inherent in the clinical problems of many patients. use conflict resolution strategies effectively in University and clinical settings and integrate constructive criticism received in University and clinical settings. correctly judge when a nursing intervention requires additional assistance and seek help from the NYUCN clinical instructor or appropriate agency health care team member. I certify that I have read, understand, and meet the NYUCN Technical Standards for Core Professional Nursing Competency Performance for progression in and graduation from the NYUCN Nursing Program. Print Name NYU ID Number Student Signature Date Program Admitted Into: BS MS MS Ad. Cert. DNP PhD (please check one) Semester Entering the Program: Fall Spring Summer (please check one) Year: 20 (please insert year) The signed form may be scanned and emailed, faxed, hand delivered, or mailed to: NYU College of Nursing 726 Broadway, 10th Floor, Room 1090 Fax: 212-995-4351 Phone: 212-992-9415 Email: nursing.healthclearance@nyu.edu If unavailable, a copy of the signed form may be left in the Clinical Affairs Office mailbox located on the 10 th floor of 726 Broadway. If you have any questions, please contact the. 3_27_13 Final Page 5 of 5

New York State Department of Health Meningococcal Disease Last Reviewed: July 2011 What is meningococcal disease? Meningococcal disease is a severe bacterial infection of the bloodstream or meninges (a thin lining covering the brain and spinal cord) caused by the meningococcus germ. Who gets meningococcal disease? Anyone can get meningococcal disease, but it is more common in infants and children. For some adolescents, such as firstyear college students living in dormitories, there is an increased risk of meningococcal disease. Every year in the United States approximately 2,500 people are infected and 300 die from the disease. Other persons at increased risk include household contacts of a person known to have had this disease, immunocompromised people, and people traveling to parts of the world where meningococcal meningitis is prevalent. How is the meningococcus germ spread? The meningococcus germ is spread by direct close contact with nose or throat discharges of an infected person. What are the symptoms? High fever, headache, vomiting, stiff neck and a rash are symptoms of meningococcal disease. The symptoms may appear two to 10 days after exposure, but usually within five days. Among people who develop meningococcal disease, 10 to 15 percent die, in spite of treatment with antibiotics. Of those who live, permanent brain damage, hearing loss, kidney failure, loss of arms or legs, or chronic nervous system problems can occur. What is the treatment for meningococcal disease? Antibiotics, such as penicillin G or ceftriaxone, can be used to treat people with meningococcal disease. Should people who have been in contact with a diagnosed case of meningococcal meningitis be treated? Only people who have been in close contact (household members, intimate contacts, health care personnel performing mouthto-mouth resuscitation, daycare center playmates, etc.) need to be considered for preventive treatment. Such people are usually advised to obtain a prescription for a special antibiotic (either rifampin, ciprofloxacin or ceftriaxone) from their physician. Casual contact, as might occur in a regular classroom, office or factory setting, is not usually significant enough to cause concern. Is there a vaccine to prevent meningococcal meningitis? There are three vaccines available for the prevention of meningitis. The preferred vaccine for people ages 2-55 years is Meningococcal conjugate vaccine (MCV4). This vaccine is licensed as Menactra (sanofi pasteur) and Menveo (Novartis). Meningococcal polysaccharide vaccine (MPSV4; Menomune [sanofi pasteur]), should be used for adults ages 56 and older. The vaccines are 85 to 100 percent effective in preventing the four kinds of meningococcus germ (types A, C, Y, W-135). These four types cause about 70 percent of the disease in the United States. Because the vaccines do not include type B, which accounts for about one-third of cases in adolescents, they do not prevent all cases of meningococcal disease. Is the vaccine safe? Are there adverse side effects to the vaccine? The three vaccines available to prevent meningococcal meningitis are safe and effective. However, the vaccines may cause mild and infrequent side effects, such as redness and pain at the injection site lasting up to two days. Who should get the meningococcal vaccine? The vaccine is routinely recommended for all adolescents ages 11-12 years, all unvaccinated adolescents 13-18 years, and persons 19-21 years who are enrolling in college. The vaccine is also recommended for people ages 2 years and older who have had their spleen removed or have other chronic illnesses, as well as some laboratory workers and travelers to endemic areas of the world. Who needs a booster dose of meningococcal vaccine? CDC recommends that children age 11 or 12 years be routinely vaccinated with Menactra or Menveo and receive a booster dose at age 16 years. Adolescents who receive the first dose at age 13-15 years should receive a one-time booster dose, preferably at ages 16-18 years. Teens who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose, as long as they have no risk factors. All people who remain at highest risk for meningococcal infection should receive additional booster doses. If the person is age 56 years or older, they should receive Menomune. How do I get more information about meningococcal disease and vaccination? Contact your physician or your student health service. Additional information is also available on the websites of the New York State Department of Health,http://www.health.state.ny.us/; the Centers for Disease Control and Prevention,http://www.cdc.gov/ DiseasesConditions/; and the American College Health Association,http://www.acha.org.au/info/general/Home/get/0/0/. Source: http://www.health.state.ny.us/diseases/communicable/meningococcal/fact_sheet.htm

Meningococcal Meningitis Vaccination Response Form This form is for new students, returning students, McGhee students, graduate students, and students over the age of 21 who do not live in a residence hall. (New students and returning students under the age of 21 must submit proof of meningitis vaccine.) RETURN FORM TO: NYU Student Health Center Immunization Record Services 726 Broadway, Suite 336 Telephone: (212) 443-1199 Fax: (212) 443-1198 New York State Public Health Law 2167 requires that all college and university students enrolled for at least (6) semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete and return this form. Check ONE box and sign below: I have (for students under the age of 18, My child has... ) 1. had the meningococcal meningitis immunization (Menomune TM ) within the past 10 years. Date received: / / Doctor s signature: Stamp: 2. I am a newly admitted undergraduate student, attest to being over the age of 21, and DO NOT reside in an NYU residence. 3. I am a graduate student and have read or have had explained to me the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I will not obtain immunization against meningococcal meningitis disease. Signature: Date: / / Print Student s Name: Date of Birth: / / University I.D. Number: Student s Email Address: Student s Mailing Address: City: State: Zip: Student s Phone Number: ( ) - ( ) - NYUStudentHealthCenter Immunization Record Services 726 Broadway, Suite 336 212-443-1199 health.requirements@nyu.edu 9/7/11