Rutgers School of Nursing Center for Professional Development 65 Bergen Street, Room Newark, New Jersey 07107

Transcription

1 p f Dear Participant, The attached health documentation is required for participation in the RN Skills Refresher course per University Policy and is 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. After the forms are completed by your provider please fax to NOW: Read through all forms in this packet Schedule an appointment with your healthcare provider for a: Physical Exam and completion of the Immunization Record. Our forms must be used and must be dated, signed and stamped by your provider. The Healthcare Provider Checklist is to be given to your healthcare provider Tuberculosis PPD testing is required prior to participation. This may consist of a two step PPD or an FDA approved blood test for TB (such as Quantiferon Gold or T-Spot). A two step PPD consists of two PPD tests placed approximately 1-3 weeks apart. Each test must be read hours after placement. A blood test for TB is an acceptable alternative. 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. If you have any questions, require additional information, or need a recommendation for a local health care provider, please contact at: If you cannot upload your completed forms, you may mail or fax them to: Rutgers School of Nursing, Room 1124 PHONE: FAX: Sincerely, Jeannette Manchester, DNP, RN Assistant Professor & Director of Center of Professional Development Cat 1 r

2 Health History and Physical Form Rutgers School of Nursing p f 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 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

3 P F 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) Telephone (cell) Male Female Street Address City State Zip 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 & 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 x mm induration PPD #2 (date placed ) PPD#2 x 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 x 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 Meningococcal Vaccine (required for Rutgers housing application), with at least one (1) dose since age 16 Page 1 Provider: please sign this form on page 2

4 P F Print name Signature Date Healthcare provider Address/Stamp Phone Fax Page 2 Cat 1 r

5 Health Care Provider Check List History & Physical A completed health history and physical exam, dated, signed and stamped by the healthcare provider, on our forms. PPD 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 # Quest Diagnostic test # 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 # Quest Diagnostic test #85803A 3 doses of Hepatitis B vaccine are required AND Hep B Hepatitis B Surface Antigen - attach lab report LabCorp test # 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 # 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 Varicella IgG titer showing immunity- attach lab report LabCorp test # Quest Diagnostic test # 54031E Meningitis Meningococcal vaccine (required for Rutgers Health Sciences housing application), with at least one (1) dose since age 16 * Students working in healthcare with documented annual PPDs may submit that documentation to fulfil this requirement. Cat 1 r1.6.15