Continuing Education
Health Screening and Immunization
All students are required to provide proof of health screening before beginning any clinical experience in the Certified Nurse Aide or Phlebotomy Technician programs.
The student must have their health care provider complete the information below or attach a copy of the information to this form and return it to the instructor by the
first week of class.
STUDENT
First Name
MI Last Name
A health care provider must complete the following or attach a copy of the requested information to the form.
HEALTH CARE PROVIDER
First Name
MI Last Name
Attending Physician, PA or APRN
Office Address
Street Address
Apt. #
City State Zip
Phone
Name of Person Completing Form
First Name
MI Last Name
Signature of Person Completing Form Date
MEDICAL AND VACCINATION REQUIREMENTS DATE REQUIREMENT WAS MET
1. Current history and physical completed within past 12 months
2. Current vaccinations (all must be documented)
a. Rubella: positive titer or proof of vaccine
b. Rubeola (measles): positive titer or, if born after December 31, 1956, must have proof of two vaccinations, one since 1980
c. Mumps: positive titer or proof of one vaccination (MMR)
d. Varicella (chicken pox): positive titer or proof of two vaccinations. History of disease is not enough.
e. Flu shot: during flu season
f. Tetanus: vaccination within the past 10 years
3. Tuberculosis (TB): one choice must be documented
a. Evidence of nonreactive PPD within past 12 months (tine not acceptable)
b. Documentation of conversion with health monitoring or documentation of treatment and resolution for prophylaxis or active TB disease OR
c. Documentation of negative QuantiFERON® – TB Gold
4. Hepatitis B: vaccine/titer or declination form
5. Influenza: vaccination
July 2019/PR
