PRE-CLINICAL HEALTH REQUIREMENTS (PCHR)-Freshman,Transfer, 2nd Degree Nursing

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1 PRE-CLINICAL HEALTH REQUIREMENTS (PCHR)-Freshman,Transfer, 2nd Degree Nursing PCHR Guidelines and General Information Academic Programs with PCHR: Duquesne University School of Pharmacy Duquesne School of Nursing Undergraduate Graduate Second degree Rangos School of Health Science Athletic Training Health Management Systems Occupational Therapy Physician Assistant Physical Therapy Speech, Language Pathology All PCHR forms are available on Duquesne University Health Service Web Site: The Pre-Clinical Requirements Coordinator is located in Duquesne University Health Service (DUHS) Phone Fax: Address: Duquesne University Health Service (attn. Carol Dougher, RN) 2 nd Floor Union 600 Forbes Avenue Pittsburgh PA, Schedule an appointment only for questions or concerns regarding requirements Appointments can be made by calling after 8:00 AM Monday-Friday What to bring (if you have already downloaded the form and collected required documents) Proof of Immunization (see individual school forms) obtain a copy of records from your MD office(make additional copies for your records) Proof of Immune Blood tests if required by your school (see individual school forms) obtain a copy of your lab results (Make additional copies for your records) The Duquesne University Health Service is able to provide: Physical Examination $50.00 PPD (two-step) $30.00 PPD (Annually) $15.00 Quantiferon Gold (Q-Gold) blood test alternative to PPD- $60.00 Immunizations can be obtained through the Duquesne University Center for Pharmacy Care Appointments for immunizations can be scheduled by calling the center at *Fees Payable by cash, check or credit card* *Fees are subject to change Blood Testing for Immunity (titers) - If required by your school can be obtained from: Personal Physician Allegheny County Health Department 4th floor Hartley Rose Building 425 First Avenue Pittsburgh, PA (between Cherry Way & 1st Ave. Next to Art Institute) (No appointment needed) M-T-Th-F 9:00 am-4:00 pm W 1:00 pm-8:00 pm All PCHR documents must be submitted electronically to Health Services through the HEALTH SERVICE STUDENT PORTAL -gain access by: (Log into DORI>select "student" from the drop down options under "Go To">select HEALTH SERVICE STUDENT PORTAL >Follow instructions in portal)

2 Entering Nursing Student Pre-Clinical Health Requirements & Instructions The following health requirements are mandatory for all newly entering nursing students. 1. Immunization Compliance Record (see Clinical Compliance Forms) MMR - 2 doses Tdap (Tetanus/Diphtheria-Acellular/Pertussis) - within past 10 years Meningitis (one MCV4 dose administered on or after the 16th birthday) Hepatitis B - series of 3 injections Varicella Vaccine (Varivax) /Chickenpox - 2 doses of vaccine OR if history of chickenpox disease, an immune blood test is required in place of the vaccine Influenza Vaccine - completed by December 1st 2. REQUIRED Blood Tests MMR titers (Measles [Rubeola] IgG / Mumps IgG / Rubella IgG) Hepatitis B Surface Antibody Varicella Titer IgG (OR proof of 2 doses of Varivax [chickenpox] vaccine) Please be advised that additional immunizations may be required for blood results which may indicate non-immunity. PLEASE READ each separate form for specific information. 3. TUBERCULOSIS skin testing (2-step PPD [Mantoux] or IGRA (T-Spot or Quantiferon Gold) 4. Physical Exam by a licensed practitioner LEVEL Duquesne University Health Service can provide Physical Exams, TB testing. Fees apply. Contact Pre-Clinical Requirements Coordinator (PCHR)to schedule: Entering Basic BSN Student Entering Second Degree BSN Student Sophomore Junior Senior REQUIREMENTS August 1 st All Entering Students Requirements above August 1 st All Entering Students Requirements above July 1 st Annual TB Test Tdap (if needed) July 1 st Physical Exam Annual TB Test Tdap (if needed) July 1 st Annual TB Test Tdap (if needed) November 15 th Influenza Vaccine November 15 th Influenza Vaccine November 15 th Influenza Vaccine November 15 th Influenza Vaccine November 15 th Influenza Vaccine READ AND SUBMIT INFORMATION AS PER INSTRUCTIONS ON EACH COMPLIANCE FORM

3 Entering Nursing Student Demographic Information Form LAST NAME: FIRST NAME: MIDDLE INITIAL: DATE OF BIRTH: PROGRAM: BSN SECOND DEGREE GRADUATE YEAR OF GRADUATION: PERMANENT STREET ADDRESS: CITY: STATE: ZIP CODE: IF INTERNATIONAL: COUNTRY: POSTAL CODE: PERSONAL ADDRESS: PERSONAL CELL PHONE: SCHOOL ADDRESS: INSTRUCTIONS FOR SUBMITTING COMPLETED REQUIREMENTS ALL PRE-CLINICAL HEALTH REQUIREMENTS MUST BE UPLOADED TO THE HEALTH SERVICE STUDENT PORTAL. Log into DORI> Select "Student" from the drop down options under "Go To"> Select "Health Service Student Portal"> Follow instructions in portal. ALL PRE-CLINICAL HEALTH REQUIRMENTS MUST BE UPLOADED TO: HEALTH SERVICE STUDENT PORTAL Please note that all douments must be uploaded to the "Entering Nursing Student Pre-Clinical Health Requirement" tab. QUESTIONS: Contact Duquesne University Health Service 600 Forbes Avenue, Pittsburgh PA Fax:

4 Entering Student Clinical Compliance #1 MMR (Measles, Mumps, Rubella) Vaccination #1 MMR (Measles, Mumps, Rubella) Vaccination #2 REQUIRED BLOOD TESTS Please complete the following titers. Attach results of laboratory tests. Rubeola ( Measles) titer results: Mumps titer results: Rubella (German Measles) titer results: Negative or Equivocal results on any of the above REQUIRE an MMR Booster MMR Booster Dose/ I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

5 Entering Student Clinical Compliance #2 Tetanus, Diptheria, Pertussis Booster (Tdap) and Meningitis Vaccination Tdap Booster required within last 10 years Tetanus, Diptheria, Pertussis (Tdap): Date of vaccination: Meningococcal Vaccine(MCV4) must be on or after 16th birthday Meningococcal conjugate (MCV4) Date of vaccination: I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

6 Entering Student Clinical Compliance #3 Hepatitis B Series Vaccination #1 Hepatitis B Vaccine - Required Vaccination #2 Vaccination #3 A positive Hepatitis B surface antibody titer is required following 3 dose series. (Either HepBsAb or antihepb) Titer Results: Attach results of laboratory tests. If titer is negative, must complete HEPATITIS B dose # 1 then REPEAT Titer. If REPEAT titer is Negative, Doses # 2 and #3 are required with a final REPEAT titer Vaccination provided following NEGATIVE titer 1 st Dose Repeat titer date and results: (If negative, Doses #2 and 3 required) 2 nd Dose 3 rd Dose Repeat Titer date and results: I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

7 Entering Student Clinical Compliance #4 Varicella Vaccine Vaccination #1 Varicella Vaccine (Chicken Pox) Vaccination #2 OR If history of disease, Varicella IgG titer required. Attach results of laboratory tests. If positive titer, no vaccination is required as immunity has been verified. Titer results: Negative titer results REQUIRE two doses of vaccine I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

8 Entering Student Clinical Compliance #5 Tuberculosis Testing 2-Step MANDATORY 2-STEP TUBERCULOSIS SKIN TEST PPD PPD (2 nd step within days of first) STEP #1 Date given: Date read: (48-72 hours after placement) Results: (>10mm induration = positive) Induration in mm NEGATIVE Result POSITIVE Result** STEP #2 OR either of following blood tests may replace the 2-step PPD Select One: Interferon Gamma Release Assay (IGRA) T-Spot/Quantiferon Gold Date obtained: Negative Positive** Chest Xray REQUIRED Copy of x-ray must be attached ** POSITIVE RESULTS (PPD > 10 mm OR Positive IGRA or T-Spot Test) Result: INH Treatment: Date Started Date Completed I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

9 Entering Student Clinical Compliance #6 Physical Examination and Student Statement TO BE COMPLETED BY HEALTH CARE EXAMINER Physical exam completed on (date) the above individual I have obtained and reviewed a health history for this individual, and have reviewed immunization status and laboratory results. I certify that this student has no physical limitations and is able to fully participate in nursing class and clinical practica. Note: ANY LIMITATIONS OR EXCLUSIONS MUST BE DESCRIBED IN AN ATTACHMENT License #: STUDENT STATEMENT (TO BE COMPLETED BY STUDENT) The information provided on the above forms (total 6 pages) is correct. Attached are copies of all required information and results. I understand that failure to complete this information may jeopardize my progression in the nursing program. I give permission for information contained in this form to be shared with faculty/staff of the school of nursing. I auhorize release of this informaion, upon request, to any organization sponsoring an experiential rotation in which I participate. I forever release & discharge Duquesne University, their respective employees and agents from any claims, damages losses, liabilities, and expenses arising out of gathering & reporting this information. THE FOLLOWING FORMS HAVE BEEN COMPLETED IN THEIR ENTIRETY AND HAVE BEEN/ARE BEING SUBMITTED: Form #1: Form #2: Form #3: Form #4: Form #5: Form #6: MMR Form Tdap / Meningitis Vaccine Form Hepatitis B Varicella TB Form Physical Exam Form and Student Statement Student

10 Annual Clinical Compliance Seasonal Influenza Vaccine Seasonal Influenza Vaccine (Must be completed by November 15 th ) Please complete and/or place sticker with information below Name of Vaccine: Manufacturer: Lot # Health Care Provider Address: City: State: Zip: Phone number: Expiration NDC# Date given: THIS FORM AND ALL SUPPORTING DOCUMENTS MUST BE UPLOADED TO DU HEALTH SERVICE STUDENT PORTAL INSTRUCTIONS TO UPLOAD TO HEALTH SERVICE STUDENT PORTAL : (Student logs into DORI>selects "Student" from the drop down options under "Go To"> selects Health Service Student Portal >Follow intructions in portal) 2/2018

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