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Completed by student FirstName MiddleInitial: LastName: Student ID#(PRINT CLEARLY)Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s LEHMAN COLLEGE DEPARTMENT OF NURSINGA N NU A L HE AL T H C L EA R AN CE R EQ U IR E MEN T SREAD ME FIRSTEach Department of Nursing student must have current health clearance prior to each clinical nursing course:Undergraduate (Generic/Accelerated, RN-BS) clinical courses: (NUR 301, 303, 304, 400, 405, 409).Graduate (Master’s/Post-Master’s Certificate) clinical courses: (NUR 700, 732, 733, 738, 739, 749.1, 749.2, 749.3,751, 752, 770, 771, 772, 773, 774, 775, 776).Health clearance is required by the New York State Department of Health to determine that health care workers and studentsdo not pose a health risk to clients, families or co-workers and to assure that the student is physically able to fulfill theobjectives of the educational program.Attached is an examination form and list of laboratory tests which must be completed and signed by a physician or nursepractitioner of your choice. The completed form, including the evaluation of lab results, must be returned to the Departmentof Nursing.Documentation of immunization/immunity to communicable disease needs to be completed only once if immunity isconfirmed.Health Clearance is valid for 12 (twelve) monthsINSTRUCTIONSStudent completes pages 3, 7, and 8 of this document. Your doctor must complete and sign pages 4, 5, and 6.Submit this original Health Clearance Form and any Lab Reports. And also attach one copy each of yourLiability Certificate of Insurance and CPR card (both sides) at the same time to the Nursing Department bythe following deadlines: New Generic/Accelerated nursing students: On or before the day of scheduled Nursing Orientation New RN-BS/Master’s/Post-Master’s nursing students: Eight weeks before the official first day of the semesterin which you have a clinical course. Also submit a copy of your NYS Registered Nurse License and Registration. All current nursing students: Eight weeks prior to the official first day of your clinical course. FAILURE TO RETURN YOUR COMPLETED, ORIGINAL HEALTH CLEARANCE FORM WITH ALL REQUIRED DATA,AND A COPY OF YOUR INSURANCE CERTIFICATE AND CPR CARD BY THE DEADLINE WILL RESULT IN YOU BEINGBARRED FROM CLINICAL WHICH WILL LEAD TO AN AUTOMATIC FAILUREMAKE EXTRA COPIES OF YOUR COMPLETED HEALTH CLEARANCE FORM, LIABILITY INSURANCE CERTIFICATE,AND CPR CARD FOR YOUR PERSONAL RECORDS.THE NURSING DEPARTMENT WILL NOT BE MAKE COPIES FOR YOU.ONCE SUBMITTED, HEALTH CLEARANCE WILL NOT BE RELEASED TO YOU TO MAKE COPIES OR TO BORROW FORUSE AT MEDICAL APPOINTMENTS/SCREENINGS.ALWAYS CARRY A SET OF THESE DOCUMENTS WITH YOU TO YOUR CLINICAL SITE.RENEW AND SUBMIT YOUR HEALTH CLEARANCE, LIABILITY INSURANCE, AND CPR TO THE NURSINGDEPARTMENT BEFORE THEY EXPIRE.RETURN COMPLETED FORMS TO: Department of Nursing, Building T-3, Room 201CONTINUE READING NEXT PAGERevised Jun 2014CAG/AA/pbPage 1 of 8
Completed by student FirstName MiddleInitial: LastName: Student ID#(PRINT CLEARLY)Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s READ ME NEXTDOCUMENT REQUIREMENTS FOR CLINICAL PLACEMENT AND PERFORMANCEGeneric/Generic-Accelerated, RN-BS, Master’s/Post-Master’s Certificate A.Submit original or copy of document as specified below in person to the Nursing Department, Bldg. T-3, Rm 201. Nursing is notresponsible for delayed/lost documents sent by mail. Check off the completion of your requirements below.Make a few copies of these documents for your own your records or personal medical use. Nursing will not make copies for you.Contact your health care provider, insurance carrier, or appropriate document issuer if you lose your documents or need copies.Carry a set of these documents with you to the clinical site to have available if requested for review/submission by the clinical sitemanager/coordinator, preceptor, or your instructor.Department of Nursing’s Health Clearance Form - Valid for 1 year from date of exam Make copies for yourself Submit completed, signed original Health Clearance to Nursing – ALL NURSING STUDENTS Carry a copy to clinical.Check-OffCompletedSUMMARY OF REQUIRED HEALTH CLEARANCE1.Physical Examination annually.2.Laboratory Tests – Evaluation of test results as “Normal” or “Abnormal” must be done by the physician. CBC with Differential Urinalysis with Microscopic exam Hepatitis B Antigen/Antibody Titre Rubella Titre – Positive titre required (give exact numbers). Immunization required if titres are not immune. Varicella (Chicken Pox) – Positive Titre required. Measles, Mumps (if no documentation of immunizations available) Immunizations3. Tetanus-Diphtheria – Within 10 years (give exact date) PPD – All students must have a PPD, including those who have previously received BCG. A chest x-ray is required atthe time of conversion and every 5 years thereafter. A copy of the radiology report must be attached to the Health Clearance Form. Students who convert to PPD positive must provide evidence that they are being treated prophylactically in order tocontinue in clinical. (Department of Health requirement)Students who are PPD negative must have a repeat PPD prior to each clinical semester. Mumps – Documentation of immunization or positive titre required. Measles – Documentation of immunization or positive titre required. Vaccines Hepatitis B Vaccine. If you decline this vaccine, then you must sign the Declination of Hepatitis B Vaccine (p 7). Influenza Vaccine. If you decline this vaccine, then you must sign the Declination of Influenza Vaccine (p 8).Additional requirements may be imposed by specific agencies with which the Department of Nursing affiliates.These include, but are not limited to: B.D.E.F.Drug and alcohol screeningBackground investigation including criminal record name searchChild Abuse and Maltreatment inquiry.Cardio-Pulmonary Resuscitation (BCLS) for healthcare providers - valid for 1-2 yearsALL NURSING STUDENTS Make copies for yourself Carry a copy to clinical.CPR training at the Nursing Department - cards will be given to students when received & copied for Nursing’s file.CPR training taken elsewhere: Submit 1 copy of each side of your signed CPR card. C.Read &UnderstoodMalpractice Liability Insurance - valid for 1 year – ALL NURSING STUDENTS Make copies for yourself Carry a copy to clinical.Check-OffCompleted Check-OffCompletedNurses Service Organization (NSO): 800-247-1500. Apply online at: e. Submit 1 copy of your Certificate of Insurance Consent to Release Documents form - Submit signed original - ALL NURSING STUDENTS RN License and Registration –- RN-BS, MASTER’S/POST-MASTER’S STUDENTS Submit a copy of your current New York State RN license and registration.Application for Clinical Placement – MASTER’S/POST-MASTER’S STUDENTS See Graduate Documents & Forms at ate-forms.phpRevised Jun 2014CAG/AA/pbPage 2 of 8
To be completedby student(PRINT CLEARLY)Student ID# FirstName: MiddleInitial: LastName:Check Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Enter your Clinical Course#: NUR Clinical Site/InstructorSemester/Year:LEHMAN COLLEGE DEPARTMENT OF NURSINGANNUAL HEALTH CLEARANCE RECORD(Expires 12 (twelve) months from date of your physical exam)NamePrint FirstMiddleLastSexAgeStreet AddressCity State Zip Phone #Lehman EmailPersonal Health History: (To be completed by the student)Have you ever had any of the following? (Circle YES or NO and indicate date)Back trouble .Yes . NoRheumatism Yes . NoAsthma Yes . NoAllergy Yes . NoTuberculosis Yes . NoEar Problems . Yes . NoSkin Problems .Yes . NoGonorrhea or Syphilis Yes . NoKidney Problems Yes . NoSeizure Disorder . Yes . NoUlcers . . .Yes . NoMental/Emotional Problems. Yes . NoCancer . .Yes . NoHernia . . Yes . NoDiabetes . Yes . NoRheumatic Fever Heart Murmur . .Yes . NoPneumonia . Yes . NoHigh Blood Pressure .Yes . NoLow Blood Pressure . Yes . NoYes . NoDescribe any items checked YES above:List previous serious illnesses/operations:Student’s Signature:Today’s Date:Revised Jun 2014CAG/AA/pbPage 3 of 8
To be completedby student(PRINT CLEARLY)Student ID# FirstName: MiddleInitial: LastName:Check Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Enter your Clinical Course#: NUR Clinical Site/InstructorSemester/Year:LEHMAN COLLEGE DEPARTMENT OF NURSINGAnnual Physical Examination: (To be completed by physician)Height:Weight:Visual Acuity: O.D.SYSTEMB.P: mmHg EMARKS (Describe Abnormalities)SkinHead & NeckNose & SinusesMouth & ThroatGums & TeethEyesEars, HearingThorax & LungsBreastHeart & VascularLymphaticsAbdomenHerniaAnus & NeurologicMental/EmotionalIs there any emotional, mental or physical condition for which this student is under medica l supervisionand/or taking medication?YesNoSpecify:Physician’s Signature:Exam Date:Revised Jun 2014CAG/AA/pbPage 4 of 8
To be completedby student(PRINT CLEARLY)Student ID# FirstName: MiddleInitial: LastName:Check Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Enter your Clinical Course#: NUR Clinical Site/InstructorSemester/Year:LEHMAN COLLEGE DEPARTMENT OF NURSINGLaboratory Test Results:Urinalysis:CBC:PPD*: NegativePositiveDateProphylaxis prescribed: YesDateChest x-ray*:Date/ResultNo*All students must have a PPD, including those who have previously received BCG. A chest X-ray isrequired at the time of conversion and every 5 years thereafter. A copy of the radiology report must beattached to the Health Clearance Form. Students who convert to PPD positive must provide evidence thatthey are being treated prophylactically in order to continue in clinical. (Department of Health requirement)Recommendation for physical activities: Full activityLimited activityIf limited activity, specify limitations:I certify that has had the required immunizations and that thephysical examination and laboratory test results are within normal limits.Physician Name:Physician Signature:Address:Phone #:Date of Exam:Revised Jun 2014CAG/AA/pbPage 5 of 8
To be completedby student(PRINT CLEARLY)Student ID# FirstName: MiddleInitial: LastName:Check Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Enter your Clinical Course#: NUR Clinical Site/InstructorSemester/Year:LEHMAN COLLEGE DEPARTMENT OF NURSINGIMMUNIZATION RECORD(To be completed by a licensed physician)Vaccination DatesTitre(Give exact numbers)Date of TitreImmune/Not laHepatitis B* (HBV)Influenza Virus Vaccine: Submit a copy of your Vaccination PrintoutDateDoseManufacturerLot NumberExpirationDateSticker NumberProvider Name/LocationVaccine Administrator: Title: Signature:Rubella titre is required. This test will tell you if you have ever been exposed to Rubella or German Measles and havedeveloped antibodies. Rubella usually results in a mild illness unless you are pregnant. Rubella during the first threemonths of pregnancy can result in congenital defects in the infant. If your Rubella titre is negative or less than 1:8, itmeans you have not developed antibodies to Rubella. A vaccine which is available through your physician willimmunize you against Rubella. If your Rubella titre is positive, you do not need any additional immunization.Titres are required for Mumps, Measles, and Varicella (Chicken Pox) unless proof of vaccination is available. If titres donot show immunity, the appropriate vaccinations are required.A Hepatitis antigen and antibody titre is required and should be done yearly. It is strongly recommended that all studentsreceive the Hepatitis B vaccine if they are not immune. If your titres indicate that you are not immune and you decline tobe vaccinated, you must sign a declination statement which is available from the secretary in the Department of Nursing.Student’s Name (print):Physician’s Signature:Exam Date:Revised Jun 2014CAG/AA/pbPage 6 of 8
To be completedby student(PRINT CLEARLY)Student ID# FirstName: MiddleInitial: LastName:Check Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Enter your Clinical Course#: NUR Clinical Site/InstructorSemester/Year:LEHMAN COLLEGETHE CITY UNIVERSITY OF NEW YORKDEPARTMENT OF NURSINGDECLINATION OF HEPATITIS B VACCINE*I understand that, due to my occupational exposure to blood or other potentially infectious materials as anursing student assigned to care for clients in the clinical setting, I may be at risk for acquiring HepatitisB Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine.Although my Hepatitis antigen/antibody titre shows that I am not immune to Hepatitis B Virus, I declineHepatitis B vaccination at this time. I understand that, by declining this vaccine, I could be at risk ofacquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure toblood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, Iunderstand that I can receive the vaccination series.Student PrintLast NameFirst NameSignature of StudentDate* Prior to signing this declination form, it is recommended that you discuss your decision with yourprimary care provider.Revised Jun 2014CAG/AA/pbPage 7 of 8
To be completedby student(PRINT CLEARLY)Student ID# FirstName: MiddleInitial: LastName:Check Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Enter your Clinical Course#: NUR Clinical Site/InstructorSemester/Year:LEHMAN COLLEGETHE CITY UNIVERSITY OF NEW YORKDEPARTMENT OF NURSINGDECLINATION OF INFLUENZA VIRUS VACCINE*I have been given the opportunity to receive the Influenza Vaccine and I have declined. I understand thatInfluenza is contagious and that by declining this vaccine I may be at risk for contracting the flu virus. Ialso risk infecting others through my occupational exposure to patients and others as a nursing studentassigned to care for clients in a clinical setting.I understand that I will be required to wear a mask in accordance with the policies of the healthcareinstitution and New York State Department of Health regulations. I understand that some healthcareinstitutions may deny my clinical placement at their site due to my declination of the Influenza Vaccine.Although I have declined at this time I understand that I can choose to receive the Influenza vaccination ata later date.Student PrintLast NameFirst NameSignature of StudentDate* Prior to signing this declination form, it is recommended that you discuss your decision with yourprimary care provider.Revised Jun 2014CAG/AA/pbPage 8 of 8
Program: Generic/Accelerated (B.S.) RN—B.S Master’s/Post-Master’s Certificate Cohort/Offsite: RN-BS or Master’s Revised Jun 2014 CAG/AA/pb Page 1 of 8 LEHMAN COLLEGE DEPARTMENT OF NURSING
