7/31/2019 Health Form Page 2 - June 2011 in PDF

1/1

June 2011 Page 2

BOROUGH OF MANHATTAN COMMUNITY COLLEGE OF THE CITY UNIVERSITY OF NEW YORKDEPARTMENT OF NURSING

Dear Provider: The Nursing Student listed below is entering their clinical rotations and is being held to these HealthCare Provider Standards by the hospitals where he/she will be doing their clinical rotation. They will NOT be allowedto start clinical until the health requirements are met EXACTLY as listed. Thank you for your assistance.

Name: __________________________________________ Date of Birth: ___________________

Tuberculin Skin Test (TST) - If you do not have documentation of a TST done in the past 12 months,then you will need to have a 2-Step test done a week apart.

Date #1 ___________________ Result __________mm ( No more than 12 months)Date #2 ___________________ Result __________mm

Or .. If you have a Positive TST ( past or present ), Chest X-ray is required every 3 years. Copy of chest X-ray report MUST be submitted X-ray - Date ____________________

Immunizations Tdap NEED Adult Pertussis vaccine Tdap Date ______________________

Required Titers - ***MUST attach copies of lab results of Varicella & MMR***

Varicella Date___________ Titer # ____________ Immune / Non-Immune / Equivocal (History of Disease no longer adequate )

Measles Date___________ Titer # ____________ Immune / Non-Immune / Equivocal

Mumps Date___________ Titer # ____________ Immune / Non-Immune / Equivocal

Rubella Date___________ Titer # ____________ Immune / Non-Immune / Equivocal

NOTE: For Varicella & MMR, if currently Non-immune/Equivocal then MUST revaccinate if appropriate and repeat titer level 4-6 weeks after revaccination. Equivocal is considered Non-Immune .

Hepatitis B Date #1 __________ Titer # ____________ Immune / Non-Immune / Equivocal Date #2 __________Date #3 __________

(Or sign declination form)

Providers Name (print): ________________________________ Date: _________________________

Signature and Title: ___________________________________ Phone#:_______________________

Address: _____________________________________________________________________________

Provider STAMP with LICENSE#:

___________________________________________________

Note: *Multiple clinical agencies are also requiring a drug screen. Please appropriately counsel the student concerningfoods/substances to avoid prior to drug screening.

**All necessary immunizations (as requirements and/or recommendations) and Tuberculosis protocol are based on thelatest guidelines of the NYC Department of Health and Mental Hygiene.