Rutgers, The State University of New Jersey Dear Continuing Education Student, The attached health documentation is required for your participation in the continuing education curriculum per University Policy. These requirements are for your protection as well as the protection of patients and staff. All RBHS policies are based on CDC recommendations and NJ state law for healthcare workers, including students. NOW: Read through all forms in this packet Schedule an appointment with your healthcare provider for completion of the History and Physical and Immunization Record If you have additional immunization records from a licensed healthcare facility, you may provide those for consideration to fulfill your requirements Give the Healthcare Provider Checklist to your healthcare provider NEXT: Submit the completed o History and Physical and Immunization Record (no other forms will be accepted) o Lab reports (titers, chest-x-ray if necessary) o Proof of a two step PPD or an FDA approved blood assay for TB (such as Quantiferon Gold) as indicated on the Immunization Record. This consists of two PPD tests placed approximately 1-3 weeks apart. Each test must be read 48-72 hours after placement. Please make sure to have your health care provider complete, sign and date all forms. Give the Healthcare Provider Checklist to your healthcare provider so that the appropriate tests are performed. Your provider may not be familiar with some of these requirements, but they are, in fact, REQUIRED. The checklist may help to avoid the wrong tests being ordered at an increased cost to you, as any cost incurred related to the above requirements is your responsibility. The healthcare provider checklist is NOT to be returned to Student Health Services. Students are expected to be current with seasonal flu vaccination. Please the completed forms to:
Immunization Record PART I: To be completed by the student. Please print or type. Last name First name MI School/Grad year/program (if SHRP or SN) DOB (month day year) Street Address City State Zip Telephone (cell) Email PART II: To be completed and signed by health care provider (all items must be completed) Date (mo day year) Results (if applicable) Health History and Physical Form Tuberculosis - Two PPDs or an FDA approved blood test are required regardless of prior BCG (unless #1 is positive) Date read PPD #1 (date placed ) PPD#1 mm induration PPD #2 (date placed ) PPD#2 mm induration FDA approved blood test for TB (eg. Quantiferon Gold) (attach report) Positive Negative Indeterminate If PPD positive ( 10 mm), is the patient free of TB symptoms? Yes No List date of positive PPD and induration mm induration Was the patient treated? Yes No For how long? FDA approved blood test for TB (Quantiferon Gold) (attach report) Positive Negative Indeterminate Chest x-ray required within the past 12 months if TB blood test is positive or not drawn (attach report) Normal Findings: Adult Tdap (Tetanus, Diphtheria & Acellular Pertusis) (Adacel or Boostrix) MMR (Measles, Mumps, Rubella) MMR Dose #1 Dose 1 MMR Dose #2 Dose 2 Dose 3 Measles (Rubeola) serologic immunity (attach lab report & list date of lab test) Immune Non-immune Mumps serologic immunity (attach lab report & list date of lab test) Immune Non-immune Rubella serologic immunity (attach lab report & list date of lab test) Immune Non-immune Hepatitis B (at least one of three doses is required prior to enrollment) Dose 1 Hepatitis B dose #1, #2, #3 Dose 2 AND serologic testing REQUIRED: Dose 3 Hepatitis B Surface Antigen (attach lab report) Positive Negative QUANTITATIVE Hepatitis B Surface Antibody Titer* (qualitative will not be accepted per CDC guidelines) (attach lab report) *Please defer the Hep B Surface Ab titer until 1-2 months after the 3 dose series is complete. Varicella (Chicken Pox) Varicella Dose #1 Dose 1 Varicella Dose #2 Dose 2 Immune ( 10 miu/ml) Non-immune Varicella serologic immunity (list date and attach lab report) Immune Non-immune Seasonal flu vaccination (if attending between October 15 and March 15) Page 1 Provider: please sign this form on page 2
Print name Signature Date Healthcare provider Address/Stamp Phone Fax Page 2 Cat 1 CE+ r3.10.15
Health Care Provider Check List History and Physical PPD A completed health history and physical exam, dated, signed and stamped by the healthcare provider, on our forms. 2-step PPD * regardless of history of having received BCG Please include date placed and date read with millimeters of induration For a PPD 10 mm now or in the past, you must submit a chest x-ray report within the last 12 months an FDA approved blood test for TB (such as Quantiferon Gold) LabCorp test # 182873 Quest Diagnostic test # 19453 Tdap Adult Tdap (tetanus/diphtheria/acellular pertussis) (Adacel/Boostrix) (one-time administration) 2 doses of Measles, Mumps, and Rubella vaccine MMR MMR IgG titers showing immunity attach lab report LabCorp test #058495 Quest Diagnostic test #85803A 3 doses of Hepatitis B vaccine are required Hep B AND Hepatitis B Surface Antigen - attach lab report LabCorp test # 006510 Quest Diagnostic test # 265F Hepatitis B Surface Antibody QUANTITATIVE titer (the result must be a number) attach lab report. If 3 doses of the Hep B vaccine have not been administered, please defer the Hep B Surface Ab titer until one month after the 3 dose series is complete. LabCorp test # 006530 Quest Diagnostic test # 51938W These are CDC recommendations for all healthcare workers. Your patient will not be permitted to matriculate without these tests. 2 doses of Varicella vaccine, at least 1 month apart Varicella Seasonal Flu Vaccine Varicella IgG titer showing immunity- attach lab report LabCorp test # 096206 Quest Diagnostic test # 54031E Seasonal vaccination required * Students working in healthcare with documented annual PPDs may submit that documentation to fulfil this requirement. Cat 1 CE+ r3.10.15
Rutgers, The State University of New Jersey Health History and Physical Form PART I: To be completed by the student. Please print or type. Last name First name MI School/Grad year/program (if SHRP or SN) DOB (month day year) Telephone (cell) Male Female Street Address City State Zip Email HEALTH HISTY (attach pages as needed) Ongoing health problems Past surgeries Allergies Medications taken regularly PART II: To be completed by the healthcare provider. PHYSICAL EXAM (Must be completed by a non relative physician, nurse practitioner, or physician s assistant) Physical exam date (within the past 6 months): Visual acuity (with correction, if any): OD OS Correction Yes No Height (inches) Weight (pounds) BMI BP Pulse Normal Abnormal Not done If abnormal, please explain: General appearance Skin (scars, tatoos) Head Eyes Ears, Nose, Throat Neck Lymph Nodes Heart Lungs Abdomen Spine Extremities Neurological Exam Healthcare provider Address/Stamp Print name Signature Date Phone Fax Cat 123 r 1.6.15