Fillable Clinical-Passport-Requirements-Form-for-Nursing-Admissions Clinical Passport Requirements

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Clinical-Passport-Requirements-Form-for-Nursing-Admissions Clinical Passport Requirements

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Student/Faculty Clinical Passport Requirements
This is a digital PDF and should not be handwritten.
By contract with your academic institution, all students and faculty participating in learning experiences at this healthcare site must meet the following health and safety
requirements. The academic institution is responsible for ensuring that requirements have been met prior to participation in the clinical experience. Records will be kept at the
academic institution and random review by the clinical affiliates will occur on a regular basis. Documentation must meet requirements at all times. Required immunizations must
include mm/dd/yyyy if available.
SUBMITTED ONCE
SUBMITTED EVERY YEAR
TUBERCULIN STATUS
TUBERCULIN STATUS
• Initial 2-step TST is required AND confirmation of initial 2-step
•
Annual TST OR
completion.
•
Annual TB IGRA test
• If no records of previous positive TB tests or more than 12 months
• If newly positive TST/IGRA results → F/U with healthcare provider
since last TST then 2-step TST OR
(chest X-ray, symptoms check and possible treatment documentation
• Negative TB IGRA test within 12 months OR
• If negative TST within 12 months → 1-step TST
• If newly positive TST or TB IGRA → F/U healthcare provider (chest X-
of absence of active M. TB disease) and may need to complete health
questionnaire.
• Previously documented positive TST results and prior negative chest
X-ray results. Complete Annual Symptom Check Form. If any “yes”
ray, symptoms check and possible treatment documentation of
responses → /F/U with healthcare provider.
absence of active M. TB disease) and need to complete health
questionnaire
• If history of positive TST → provide results of TST reading, provide
proof of chest X-ray documenting absence of M. TB, medical treatment
and negative symptom check
• If history of BCG vaccine → TST Skin Testing as above or TB IGRA. If
INFLUENZA
• Proof of seasonal vaccination(s) OR
• Signed declination for student/faculty who decline vaccination
-
Specific healthcare institutions may require vaccination without
exception (i.e., no declination) http://flushot.healthmap.org/
negative → OK; If positive → follow-up as above
BACKGROUND CHECKS
HEPATITIS B
• Series of 3 vaccines completed at appropriate time intervals and post
vaccination titer at 6-8 weeks after series completion. If negative titer,
then repeat series (consisting of doses #4—#6) and repeat titer 6-8
weeks after#6 dose. OR obtain challenge dose #4 and re-titer after 6-8
weeks OR
• Provide results of positive titer (anti-HBs or HepB Sab) OR
• Signed declination for students/faculty who decline vaccination
-
Specific healthcare institutions may require vaccination without
exception (i.e., no declination)
• National Criminal Background Check and Washington State Patrol
Background Check (WATCH) upon admission/re-admission and re-
entry/hire to program to include all counties of residence & all
Washington State counties per RCW43.43.830 and OIG and GSA
screens. Excluded Provider search on:
1. OIG http://exclusions.oig.hhs.gov/ (conducted bi-monthly by
CPNW)
2. GSA http://www.sam.gov (conducted bi-monthly by CPNW)
• Washington State Patrol Background Check (WATCH annually
thereafter)
• Disclosure Statement (annual) and kept on file by education institution
MMR (Measles, Mumps, Rubella)
• Proof of vaccination (2 doses at appropriate intervals) OR
• Proof of Measles immunity by titer and
• Proof of Mumps immunity by titer and
• Proof of Rubella immunity by titer
LICENSE (If individual is licensed as any healthcare provider [RN, LPN, NAC,
etc.] and in what specific State)
• Current
• Unencumbered
INSURANCE
VARICELLA
• Professional Liability $1,000,000/3,000,000 policy (This may be
• Proof of vaccination (2 doses administered at least 4 weeks apart) OR
coverage via the school or individual)
• Proof of immunity by titer
ADDITIONAL REQUIREMENTS (if applicable)
TETANUS, DIPHTHERIA, PERTUSSIS (Tdap)
Some healthcare settings may have additional requirements, such as the
• Tdap required once after age 11
• Td required every 10 years after Tdap
following:
• Vehicle Insurance (for access to VA & Military Facilities)
• Personal Health Insurance
CPR
• Drug Screen
• American Heart Association (AHA) BLS Provider Card only
• Hepatitis A Vaccine
• Current First Aid Card
AUTHORIZATION FOR RELEASE OF RECORD
• Proof of U.S. Citizenship
• Kept on file by education institution
• Color Vision Test
REQUIRED EDUCATION
• Food Handlers License
• Each healthcare organization will communicate to faculty and students
Students and Faculty will be informed prior to clinical experience if optional
any required educational content to be completed prior to participation
or additional requirements need to be met.
in the clinical experience.
Clinical Placements Northwest ©2019
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Clinical Placements
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Student/Faculty Clinical Passport Requirements
This is a digital PDF and should not be handwritten.
All dates should be submitted in the following format: m/dd/yy
Student/Faculty Name:
__________________________________________________________
College:
_____________________________________________________________________________
Program:
_____________________________________________________________________________
Form Verified By:
_____________________________________________________________________________
Name:
__________________________________________________________
Name:
__________________________________________________________
Name:
__________________________________________________________
SUBMITTED ONCE
SUBMITTED EVERY YEAR
TUBERCULIN STATUS
A.
Two-step TST#1
Place Date:_______________ Read Date:______________
Result mm:_______________ Neg:_______ Pos:______
Two-step TST#2
Place Date:_______________ Read Date:______________
Result mm:_______________ Neg:_______ Pos:______
B.
TB IGRA
Date:_______________ Result:_______________
C.
If New Positive TST or IGRA Exam/X-ray
Date:_________ OR
D.
Positive TST or IGRA/Negative X-ray
Date:_________
TUBERCULIN STATUS
A.
Annual TST (given less than one year from previous TST)
Date:_______________ Result Neg_____ Pos_____ mm_____
Date:_______________ Result Neg_____ Pos_____ mm_____
Date:_______________ Result Neg_____ Pos_____ mm_____
B.
Annual TB IGRA (drawn less than one year from previous IGRA)
Date:_______________ Result:_______________
Date:_______________ Result:_______________
Date:_______________ Result:_______________
C.
If New Positive TST or IGRA Exam/Chest X-ray
Exam Date:_______________ X-ray Date:_______________
D.
For Known Positive/Possible Treatment: Complete Annual
symptom check
Date:_______________________
HEPATITIS B (3 primary series shots [at 0, 1, 6 months] plus titer confirmations
6-8 weeks later)
A.
Vaccination Dates
1. ______________
2. ______________
Immunity by titer
3. ______________
Date:_______________ OR
B.
If negative titer after initial series of 3 vaccines, then vaccine #4 and
re-titer OR #5 and #6 vaccines and re-titer
1. ______________
2. ______________
Immunity by titer
3. ______________
Date:_______________ OR
C.
Immunity by titer (anti-HBs or HepB SAb)
Date:______________
D.
Signed declination
Date:____________
E.
History of disease
Date:____________
Known non-responder
INFLUENZA (Effective Dates: 8/31/2019–6/30/2020)
A.
Which healthcare provider administered vaccine?
_______________________________________________
B.
Proof of seasonal vaccination
Date:____________________
Date:____________________
Date:____________________
Date:____________________
C.
Signed Declination
Date:_____________________
BACKGROUND CHECK
A.
National Criminal Background Check Including the
Exclusion Provider Search on OIG and GSA upon
admission.
Date:_____________________
B.
Provider Search: OIG/GSA—Automatically (run bi-monthly on 1st
and 15th of every month per CPNW)
Student on-boarded before cycle: manually run on
______________________________
C.
Washington State Patrol Check (WATCH) upon admission
and then annually.
Date:_____________ ; ______________
_______________ ; ________________ ; _______________
D.
Disclosure Statement annually (School keeps this on file)
Date:_____________ ; ______________
_______________ ; ________________ ; _______________
MMR (Measles, Mumps, Rubella)
A.
Vaccination Dates
1. __________________ 2. __________________ OR
B.
Immunity by titers: Measles titer
Date:_______________
Mumps Titer
Date:_______________
Rubella Titer
Date:_______________
VARICELLA (Chicken Pox)
A.
Vaccination Dates
1. __________________ 2. __________________ OR
Immunity by titer
Date:_______________
LICENSE (Any healthcare license, registration)
A.
State:_______________ License#__________________________
Expiration date:_____________________ OR
B.
_____Not Applicable
TETANUS/DIPHTHERIA/PERTUSSIS
(Tdap required after age 11)
A.
Tdap
Date:______________
B.
Td
Date:______________
INSURANCE
A.
Professional Liability Policy
Expiration Date:_____________ ; _____________
AHA/BLS COURSE (Course must be American Heart Association (AHA) BLS
provider.)
A.
Expiration
Date:______________
AUTHORIZATION FOR RELEASE OF RECORD (School keeps this on file)
ADDITIONAL REQUIREMENTS (If Applicable)
The healthcare organization may have additional requirements
that must be completed.
_____________________________ Date:_______________
_____________________________ Date:_______________
_____________________________ Date:_______________
REQUIRED EDUCATION
All students and faculty must complete ALL student learning modules on the
CPNW website. Any questions, please consult your program.
Each healthcare organization will communicate to faculty and students any
required educational content to be completed prior to participation in the
clinical experience.
Clinical Placements Northwest ©2019
South Puget Sound Community College
Nursing
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Completed 28 November 2019

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