South university nursing program requirements

Nursing Capstone.

NSG4076 RN-BSN SYNTHESIS

RN-BSN STUDENT INFORMATION PACKET

2018

Revision: Jan 2018

BPC :

13

TABLE OF CONTENTS
Preface 1

Health Promotion Project 2

Practicum Site Affiliation Agreement 2

Sponsor/Preceptor Selection 3

Project Proposal. 3

Reflective Practicum Journal 3

Clinical Hours Log 3

Student Evaluation of the Practicum Experience 3

Review of Students 3

Practice Setting Requirement 3

Students Health Requirements 4

Health Insurance 4

Valid Nursing License 4

Students Liability Insurance 5

Cardiopulmonary Resuscitation 5

Comprehensive Background Check 5

Drug Testing 6

HIPAA / OSHA Policy 6

Sponsor/Preceptor Responsibilities 7

Students Responsibilities 8

Course Faculty Responsibilities 9

Students Checklist for Planning Practicum Experience 9

APPENDICES

Appendix A RN-BSN Practicum Proposal 11

Appendix B Direct Activities Log 12

Appendix C Indirect Activities Log 13

Appendix D Review of Students by Sponsor/Preceptor 14

Appendix E Students Evaluation of Practicum Experience 15

Appendix F Students Health Assessment Form 16

Appendix G CastleBranch Clinical Requirements 18

See suprograms.info for program duration, tuition, fees, and other costs, median debt, salary data, alumni success, and other important info.

PREFACE

The purpose of this information packet is to serve as a reference for College of Nursing policies and information about the practicum course, NSG4076, RN to BSN Capstone Synthesis. Students are required to read this information packet and the South University RN-BSN Students Handbook to promote effective communication and positive student outcomes. The College of Nursing revises information and policies contained in this information packet periodically and will keep students informed of any such changes.

The clinically focused capstone course in the RN-BSN program reflects the requirements of our accrediting body, the American Association of Colleges of Nursing (AACN). AACN released a position statement in 2012, requiring practice experiences for all baccalaureate students, including RN-BSN students. This clinical experience should lead to the development of higher-level psychomotor skills and critical thinking for the RN-BSN students.

Practice experiences for the RN-BSN include direct and indirect care.

The following definitions of direct and indirect care (listed below) can be found in the AACN white paper Expectations for Practice Experiences in the RN to Baccalaureate Curriculum (AACN 2012, p. 3):

· Direct care refers to nursing care activities provided at the point of care to patients or working with other healthcare providers that are intended to achieve specific health goals or achieve selected health outcomes. Direct care may be provided in a wide range of settings, including long term care, home health, community-based settings, and education settings (Suby, 2009; Upenieks, Akhavan, Kolterman, et al., 2007).

· Indirect care refers to nursing decisions, actions, or interventions that are provided through or on behalf of patients. These decisions or interventions create the conditions under which nursing care or self-care may occur. Nurses might use administrative decisions, population or aggregate health planning, or policy development to affect health outcomes in this way (Suby, 2009; Upenieks, Akhavan, Kotlerman, et al., 2007).

NSG4076 course description:

In this clinical course, the student integrates and synthesizes the curricular components of assessment, health promotion/clinical prevention, research, professionalism, teaching, leadership, information management and technology, as well as healthcare policies to create and implement a clinical project relating to the healthcare needs of an aggregate within the community. Creation and implementation of the project will include direct and indirect care of clients in the selected aggregate.

This is the last course in the students’ program of study. The focus of this practicum is community health. The following information provides guidance in the implementation of a community health and population-focused health promotion activity. A final note: Throughout this course, the student will draw on previous learning. Students may also find that previously completed course assignments, projects, and textbooks are useful for completing the assignments in this course.

Additional information about the clinical practicum is located in the practicum preparation classroom modules (for online students).

HEALTH PROMOTION PROJECT

Students will use a community assessment model (e.g. Community as Partner) to do an abbreviated assessment of their selected aggregate/community. The students will create or obtain materials from the agency for the project. The assessment must include data collection and a windshield survey. The students will perform a data analysis to determine trends showing strengths and weaknesses that may identify community health problems for a particular aggregate at-need or at-risk. The students will then collaborate with a community agency to develop a nursing care plan and implement a health promotion project to address the problems and needs of the aggregate. The students in collaboration with the community agency will implement the health promotion project.

An evaluation of the entire project must be included. The entire process requires study and interpretation of content from NSG4074 Health Promotion and Clinical Prevention.

Students will identify a community health concern of a specific aggregate population to plan and implement a health promotion project to address this issue.

The students will select an aggregate population. (Note: the students will not be able to select a client population from their place of employment.) This is a community project; in-patient groups are not appropriate for this project. The students will need to select a population that they may physically access. The students may choose their community, county, city, or another group or organization. Some examples include:

1. Senior citizen's center

1. School or a particular grade level in a school

1. Faith based group

1. Support group

1. Non-profit organization (e.g., AHA, ADA, Alzheimer’s)

1. Day care

1. Local public health department.

Students will be required to meet with their selected patient aggregation. The purpose of these meetings will be to conduct an environmental assessment; assess the aggregate, family, and the community where the aggregate resides; and then implement a health plan with a group from the aggregate.

Students will be working with a student identified organization and sponsor /preceptor in this clinical course. Students are required to complete 150 clinical hours – indirect care accounts for 110 hours and direct care accounts for 40 hours. Indirect hours include – time students spend with preceptors discussing the community assessment, identifying a project for the community, and completing research for the project. The direct care time includes the time students are actually completing the community assessment, and presenting health promotion projects to community members. Students should plan to allocate at least 15 hours per week for the practicum experience (150 hours/practicum).

PRACTICUM SITE AFFILIATION AGREEMENT

Approval of the practicum site must be complete 1 month prior to the start of class. A clinical affiliation agreement is required for students’ practicum site. This process can take weeks to several months to obtain approval. Begin to plan this community experience early.

SPONSOR/PRECEPTOR SELECTION

The sponsor/preceptor must hold a decision making position at the facility. This person could be an employee or volunteer if a non-profit organization. The sponsor/preceptor must be able to provide access to the aggregate and assist the students in planning, implementing and evaluating the students’ project. A CV or resume’ of the preceptor/sponsor is required.

PROJECT PROPOSAL

The project proposal is due 1 month prior to the start of class. The students must submit the Project Proposal form to the Assistant Clinical Coordinator (online students) for approval by the Program Director or the campus Program Director. The students will also submit the proposal to the course faculty at the start of the course. (Form is included in packet).

REFLECTIVE PRACTICUM JOURNAL

A reflective journal will be submitted focusing on students’ health promotion project and practicum goals.

CLINICAL HOURS LOG

Please note that students are required to keep a log of clinical hours using the Verification of Clinical Hours form. Students will record direct and indirect hours in their clinical hour’s log. The clinical sponsor/preceptor must sign the clinical log and submit to course faculty as directed. (Form is included in packet).

STUDENTS’S EVALUATION OF THE PRACTICUM EXPERIENCE

Students must complete an evaluation of the practicum experience. (Form is included in packet).

REVIEW OF STUDENTS

The sponsor/preceptor will complete a final review of the student and submit the completed review to the course faculty as directed.

PRACTICE SETTING REQUIREMENTS

· A practice setting is defined as any time students have contact involving patients, patient care settings, students or student learning settings, or community organizations for a University project or course requirement.

· Students are responsible for having an approved letter of agreement (Affiliation Agreement) in place when practicing.

· Students are responsible for ensuring that the letter of agreement (Affiliation Agreement), sponsor/preceptor information and all other necessary documents are received at least 30 days prior to the start of the session.

· Practicum locations must meet the course objectives for the enrolled course. Program Directors approve all practicum locations. Students may not enter a practice setting until official notification from the Program Director or faculty has been received. Hours spent at a clinical site that has not received final approval will not count.

· Practicum rotations at the students’ place of employment is prohibited.

· Students may only be involved in obtainment of practicum hours with students South University approved sponsor/preceptor. Students may NOT utilize other individuals at the facility without prior approval of the course faculty.

· Students must wear nametags (Photo ID) identifying them as a South University students and a professional lab coat with South University emblem (if a lab coat is required by the facility).

· Attire must be professional and appropriate to the setting.

· Communication for students occurs through students’ university email addresses. If students do not have a South University email address or do not know how to access it, check with the Academic counselor (online students) or Program Director (campus students).

STUDENTS HEALTH REQUIREMENTS

Students are required to obtain a health assessment at least four (4) weeks prior to the start of their clinical experience and each year while in the program. Hepatitis B, Mumps, Measles, Rubella, Rubeola, and Varicella Titers and/or vaccinations are required. An annual assessment for TB is required. A PPD or QuantiFERON test is required. If a positive tuberculosis screen is reported, students must submit one negative Chest X-Ray report with the original Health Assessment and obtain an annual physical examination to rule out active chest disease. TDAP is required within 10 years.

Students will submit completed health assessment forms to CastleBranch. (Online students, the form is included in packet and available in the modules).

Students who are on a medical leave will need to obtain a medical clearance prior to returning to the practicum setting.

HEALTH INSURANCE

South University requires nursing students to carry Health Insurance or comparable coverage for emergency medical care. Some of the clinical facilities and agencies require proof of health insurance coverage prior to students’ participation at clinical sites. Students are responsible for any expenses related to any illness or accidents that may occur while participating in the South University nursing program. Submit a copy of students’ insurance card and signed attestation to CastleBranch.

VALID NURSING LICENSE

A valid unencumbered* license as a Registered Nursing in all U.S. state or territory which the student is licensed, including the state in which the student completes all assignments for the program. (Note that military, federal and foreign educated nurses must meet this state requirement for nursing licensure.) An unencumbered license(s) must be maintained throughout the program. It is the student’s responsibility to inform the Program Director and/or Academic Clinical Coordinator if the student’s license(s) becomes encumbered. Failure of such notification of encumbered status can lead to failure to progress in the program. If relocating, please ensure that the RN-BSN program is approved for clinical placement within that state. Contact the Program Director (campus students) or Academic Counselor (online students) for this information.

*Unencumbered License – A license that is not revoked, suspended, or made probationary or conditional by the State licensing or registering authority as the result of disciplinary action. A copy of student’s current license must be on record with CastleBranch.

STUDENTS’ LIABILITY INSURANCE

South University provides professional liability insurance to all students attending practicum courses. This policy is limited to students participating in their clinical practicum courses taken at South University.

CARDIOPULMONARY RESUSCITATION

Students must provide proof of completion of the American Heart Association Health Care Provider level CPR course prior to participation in any practicum course. Students agrees to maintain current CPR Provider status throughout their attendance at South University. Students cannot attend any practicum experience without a valid CPR card. A copy of a valid CPR card must be on record with CastleBranch.

COMPREHENSIVE BACKGROUND CHECKS

Nurses are entrusted with the health, safety and welfare of patients. The nursing curriculum contains a didactic and clinical component. Clinical facilities where student nurses practice are required by accreditation agencies to obtain background checks for security purposes on individuals that render patient care.

All students applying for the South University nursing program are required to obtain a criminal background investigation (Level 2) prior to starting the first day of class. Any students who fails to provide a background check prior to the first day of the term when their enrollment begins will be unregistered from class and will not be allowed to attend class until the background check is provided. A student's failure to provide a criminal background check prior to their start date will result in the following:

• Removal from class

• Cancellation of enrollment

• No final course grades

• No transcript

Students are responsible for the cost of the criminal background investigation. Certification of a clear criminal/background history is required to place students in clinical environments. A student whose investigation shows a felony conviction or findings/misdemeanors that constitute a significant breach of moral or ethical conduct cannot be cleared for clinical and thus will be withdrawn from consideration or if accepted must withdraw or cancel from the nursing program. During the nursing program, an enrolled student must notify the program director or clinical coordinator of a criminal conviction and/or of behaviors that constitute a significant breach of moral or ethical standards. Annual updates will be required during the program of study. A felony conviction and/or behaviors/misdemeanor conviction that constitute a significant breach of moral or ethical standards will result in immediate dismissal from the nursing program.

Acceptance into a South University educational program, or its completion, does not imply or guarantee that a student will be able to obtain such licensure or certification.

The Nursing Program Director may be required to submit written documentation regarding student status to boards of nursing and clinical agencies as early as upon receipt of the student’s CON application. Students may be required to obtain additional background checks as requested by clinical agencies or boards of nursing.

Comprehensive Background Directions:

Overview: Castlebranch.com is a service that allows students to order their own background check online. All drug testing information is obtained through Castlebranch.com. Information collected through Castlebranch.com is secure, tamper-proof, and kept confidential. The services performed by Castle Branch are based on guidelines provided by students’ organization, so students get the information students need, all from one source. The results are posted on the Castlebranch.com website where the students, as well as the school, can view them.

Ordering Instructions:

1. Go to www.Castlebranch.com and click on "Place order."

2. In the Package Code box, enter the package code provided by the Campus Program Director or Assistant Clinical Coordinator.

3. Enter payment information – Visa, MasterCard, or Money Order. Follow the online instructions to complete students’ order.

Retrieval Instructions

Once an order is submitted, students will receive a confirmation email containing the password needed to view the results of students’ background check. To view student results, visit www.Castlebranch.com , and enter password in the area provided on the lower right side of the homepage, then enter the last four digits of students Social Security Number. Results are typically available in approximately three days, though some searches take longer so please allow adequate time when ordering. The Program Director will be able to view student results in CertifiedBackground.com once complete. For A Summary of Students Rights Under the Fair Credit Reporting Act visit www.ftc.gov .

DRUG TESTING

Many health care facilities require that all persons caring for patients submit to drug screening. Students will submit to urine drug screening during the RN-BSN program and as required by practice facilities. Students who refuse to obtain a urine drug screen or have a positive urine drug screens may NOT attend clinical practice courses, which could result in dismissal from the nursing program. A student with a positive urine drug screen will be required to obtain medical clearance to assess “fitness for duty”. Students are responsible for the financial costs of required drug tests. Students without medical justification for positive drug screen will be removed from the program.

HIPAA/OSHA POLICY

All students are required to submit a current (within the last 12 months) certificate of completion for HIPAA and OSHA training . South University will accept a certificate of completion from student’s employer, as most nurses complete this training as part of an annual competency.

Documentation of HIPAA/OSHA training is required prior to entering the practicum site. Students may send a certificate of completion from students’ employer (completed in last 12 months), or find an online site that provides training (suggestions are noted below). In addition to HIPAA, required OSHA training must consist of blood borne pathogens and hazard communication training. Students are responsible for submitting the certificate of completion to the CastleBranch site.

There are many HIPAA/OSHA training sites on Internet. The sites listed below are not endorsed by South University, but appear to meet all of the requirements for HIPAA/OSHA training. Students may also find students own online sites for HIPAA/OSHA training.

*HIPAA and OSHA training is at the expense of the students since it is required by clinical facilities prior to practicum placement.

HIPAA

· HIPAA Training.com: https://www.hipaatraining.com/hipaa-training-for-healthcare-providers

· HIPAA General Awareness Training Course My HIPAA Training: http://myhipaatraining.com/

Basic HIPAA Training Course

OSHA (blood borne pathogens and hazard communication needed)

OSHAcademy Occupational Safety & Health Training: http://www.oshatrain.org/courses/index.html

· Hazard Communication Program (Course number 705)

· Blood borne pathogens (course number 755)

Although the courses are free there is a cost to download the certificate needed.

All clinical requirements, including but not limited to physical, background check, drug screen, vaccines, and trainings are to be updated annually. There are no exceptions to this rule.

SPONSOR/PRECEPTOR RESPONSIBILITIES

The following responsibilities are identified and will be used as a guide for the clinical practicum experiences:

The practicum sponsor/preceptor will:

· Orient students to the setting including identification of facility policies and procedures.

· Become familiar with course objectives.

· Provide documentation of student’s hours at mid-term and at completion of the course.

· Maintain open communication with Faculty and Students and provide current phone numbers, address and email.

· Supervise the students in the facility setting.

· Provide suggestions that will assist students in developing and implementing the proposed project.

· Contact course faculty member concerning any issues that may arise.

· Complete a final review of the students.

STUDENTS RESPONSIBILITIES

The students will:

· Comply with all academic, clinical or community facility policies and procedures.

· Comply with all South University College of Nursing policies and procedures identified in the University Catalog and/or RN-BSN Students Handbook. Failure to exhibit integrity, ethical conduct, or professional standards may warrant dismissal from South University.

· Establish with sponsor/preceptor, the Project Proposal and successfully complete the terms established within it.

· Adhere to all practicum facility policies.

· Be present at the approved practicum site with the approved sponsor/preceptors for the specified course.

· Ensure sponsor/preceptor has a copy of the current course syllabus.

· Identify project goals for the practicum experience with course faculty and practicum sponsor/preceptor. Review learning goals before starting the practicum with course faculty and practicum preceptor.

· Comply with health and other professional requirements of the clinical facility prior to the start of the practicum experience.

· Be prepared to work in the practicum setting in a safe manner that demonstrates professional standards and arrive at the agreed time.

· Attend all established practicum days, or notify sponsor/preceptor and faculty of absence and establish clinical make-up experience.

· Dress in a professional manner consistent with clinical facility guidelines and be clearly identified as being a South University student. ID Badges and lab coat must be worn at all times in the community/practicum settings identifying the students as a South University student.

For online students, contact SUOIDrequest@southuniversity.edu to obtain an ID badge.

For online students, in order to provide students with an ID card, please provide the following information:

· Full Name

· Students ID Number

· Mailing Address

· Name of the Program

· Headshot Photo:

· jpeg format (less than 100kb)

· Front face (no profiles)

· No sunglasses or hats/headgear

· Copy of Driver’s License

ID Badges should be ordered 5 weeks in advance of enrolling in the first practicum course.

Lab coat

· Students are to order their lab coat through MEDWEAR. Note that ALL EMBROIDERED ITEMS ARE A FINAL SALE. Please allow up to 5 weeks for delivery.

http://medwearuniforms.com/group-sales/southuniversity/onlinestudentstore.php

.

COURSE FACULTY RESPONSIBILITIES

The course faculty member will:

· Establish communication between sponsor/preceptor and the faculty member.

· Be available to sponsor/preceptor to discuss any issues that may arise with the students.

· Counsel with sponsor/preceptor and students during the course.

· Identify students at risk and notify the program director by midterm.

· Initiate and follow up on remediation plans as needed.

· Maintain active communication with the students regarding classroom and clinical performance.

· Maintain responsibility for the final grade determination based on the grading rubric and the clinical performance evaluation.

STUDENT CHECKLIST FOR PLANNING PRACTICUM EXPERIENCE

· The student is responsible for researching, identifying and contacting a facility or organization and arranging for the Practicum experience.

· The student must obtain agreement from an individual in a position to act as the sponsor/preceptor.

· The Clinical Coordinator and/or Program Director must review and approve the arrangement prior to start of the practicum courses.

· The student MUST provide the sponsor/preceptor with a copy of the Practicum Information Packet.

· The student MUST direct the sponsor/preceptor to complete and sign the Practicum Proposal form. All information must be provided on the agreement including the sponsor’s/preceptor’s position title, licensure information, if applicable, and contact information (telephone number, CV/resumé, and email address).

· The Affiliation Agreement must be executed between South University and the clinical setting institution. PLEASE NOTE: the Affiliation Agreement is usually reviewed by legal counsel of the clinical site facility. This may take some time to complete. Students are advised to start the process as soon as possible prior to the start of the academic session in which the Practicum will be started.

· Submit the signed Affiliation Agreement and Practicum Proposal to the South University Clinical Coordinator and/or Program Director prior to the start of the practicum.

· In general, two copies of the signed affiliation agreement are forwarded to the Clinical Coordinator and then one copy of the signed and fully executed affiliation agreement is returned to the practicum institution.

· Prior to starting the Practicum Course, all documents must be completed and the arrangements for the practicum approved by the Clinical Coordinator. The agreement MUST be in place one-month PRIOR to the students engaging in any practicum experiences at the designated practicum institution.

· Students will maintain contact with their professor in the Practicum Course. There will be contact between the student’s South University Professor and his/her Practicum Sponsor/Preceptor during the practicum experience via telephone and or email.

· The student will complete a log of his/her practicum experiences.

APPENDICES

SOUTH UNIVERSITY

College of Nursing AND PUBLIC HEALTH

RN-BSN DEGREE Program

RN-BSN Practicum Proposal

Please complete this document outlining student’s proposed site and planned project. This form must be returned to student’s Clinical Coordinator for approval by the Program Director. The proposal must be submitted 4 weeks prior to the start of class. Review the course syllabus for objectives.

Student Name: Date Submitted: Course Start Date:

Contact Method:

Phone:

Email:

Practicum Information

Agency/Organization:

Address (street/city/state/zip):

Phone Number: Fax Number:

Sponsor/preceptor Person’s Name:

Position at agency:

Sponsor/preceptor Signature:

APPENDIX B

SOUTH UNIVERSITY

COLLEGE OF NURSING AND PUBLIC HEALTH

RN-BSN DEGREE PROGRAM

DIRECT ACTIVITIES LOG

This log is to start on the first day that the students is physically present at the Practicum site and begins working with his/her contact person. It continues until the Practicum is completed. This signed form must be submitted by student’s sponsor/preceptor via email to the course instructor at week five and week nine.

The total number of clinical hours required is 150, direct care hours’ minimum is forty (40).

Student Name: Practicum: Organization:

First date at Practicum site: Course Start Date:

Date

Hours completed

Direct

Brief Description of Activity

Total Hours

Total Number of Hours Completed:

Sponsor/Preceptor Signature: Date:

Student Signature: Date:

Total Number of Hours Completed:

Sponsor/Preceptor Signature: Date:

Student Signature: Date:

APPENDIX C

SOUTH UNIVERSITY

College of Nursing AND PUBLIC HEALTH

RN-BSN DEGREE Program

INDirect Activities log

This log is to help students track student’s indirect care hours. The total number of clinical hours required is 150, indirect care hours’ minimum is one hundred ten (110). This form must be submitted every other week with student’s journal to allow student’s course facilitator to be sure students are staying on track with student’s hours. The sponsor/preceptor will email the signed log to the classroom faculty in weeks 5 and 9.

Students Name: Practicum: Organization: Course Start Date:

Date

Hours completed

Indirect

Calculate the number of indirect hours each every other week when submitted

Brief Description of Activity

Total Hours

Total Number of Hours Completed:

Sponsor/Preceptor Signature*: Date:

Student Signature: Date:

Total Number of Hours Completed:

Sponsor/Preceptor Signature*: Date:

Student Signature: Date:

*My signature confirms only those indirect student hours at the facility

APPENDIX D

SOUTH UNIVERSITY

COLLEGE OF NURSING AND PUBLIC HEALTH

RN-BSN DEGREE PROGRAM

REVIEW OF STUDENT BY SPONSOR/PRECEPTOR

Student Name:

Site/Sponsor/Preceptor:

Date: Course

Please review the student by responding to the items below. Student comments are valuable. If student has any questions or concerns, please contact the course instructor.

Use the following scale to complete the student review:

SA Strongly Agree

A Agree

U Uncertain

D Disagree

SD Strongly Disagree

The student:

1. Consistently demonstrates caring behavior to members

of aggregate and facility. SA A U D SD

2. Was punctual and present in the facility as arranged. SA A U D SD

3. Wore professional attire and identification. SA A U D SD

4. Came to the facility prepared to participate and learn. SA A U D SD

5. Project presented accurate information that met the needs

of the aggregate. SA A U D SD

Additional Comments:

Sponsor/Preceptor Signature: Date:

APPENDIX E

SOUTH UNIVERSITY

College of Nursing AND PUBLIC HEALTH

RN-BSN DEGREE Program

STUDENT EVALUATION OF PRACTICUM EXPERIENCE

Complete this evaluation form and submit to the course instructor via the Dropbox in Week 10 of the Practicum course. Answer all questions please. The Practicum is not considered complete until this form has been submitted.

Student Name: Preceptor Name: Agency/Organization Name:

Practicum Start Date: End Date Form Completed/Submitted:

Describe the initial goals and objectives of the project. Were the goals and objectives met?

Why or why not?

Describe the major (3‐5) activities

related to student’s Practicum and how much time (%) was spent on each.

Do students think those activities

contributed to student’s learning experience? If so, which activities did students find most helpful and least helpful?

What do students this were the most important skills that students gained through this experience?

List the core competencies addressed through student Practicum.

Would students recommend this agency/organization to others for a Practicum? Why or why not?

Describe student working relationship with the Preceptor.

How could this experience be improved?

Student signature: _________________________________________Date: _________________

APPENDIX F

SOUTH UNIVERSITY

College of Nursing AND PUBLIC HEALTH

RN-BSN DEGREE Program

STUDENTS HEALTH ASSESSMENT FORM

Name Date / /

Address

Date of Birth / / Male Female Phone

Please note: This health assessment must be completed by an MD, DO, PA or ARNP. Assessment by other health care providers will NOT be accepted.

PHYSICAL ASSESSMENT

Height Weight Vital Signs: BP __________P _________R _________ Temperature___________

Visual Acuity (R) (L) Uses Eyeglasses YES NO Uses contact lens YES NO

Hearing Acuity (R) (L) Uses hearing aid YES NO

Immunization Record (must include dates)

MMR 1. Date / / Hepatitis Series 1. Date / / 2. Date / / 2. Date / /

Varicella 1. Date / / 3. Date / /

2. Date / /

Seasonal flu Date / / Tetanus Diphtheria acellular pertussis (Tdap) Date /

MEDICAL HISTORY:

PHYSICAL ASSESSMENT (CONTINUED)

Normal

Abnormal

Comments if Abnormal

Skin

HEENT

Heart

Lungs

Abdomen

Musculoskeletal

Neurological

THE FOLLOWING DIAGNOSTIC TESTS MAY BE REQUIRED:

Please attach a copy of all lab results including titer levels

TITERS:

DATE

IMMUNE

NON-IMMUNE

Rubeola (if no proof of vaccines)

Rubella (if no proof of vaccines)

Mumps (if no proof of vaccines)

Varicella (if no proof of vaccines)

Hepatitis B (required if immunized)

Urinalysis

DATE

NORMAL FINDINGS

ABNORMAL FINDINGS

Hemoglobin/Hematocrit

DATE

NORMAL FINDINGS

ABNORMAL FINDINGS

*PPD

1 Step (Quantiferon, Mantoux, or T-Spot)

DATE

POSITIVE

NEGATIVE