Please submit supporting documentation of immunization records and lab results. This completed form must be presented to the
instructor during the first class meeting.
Student Name:
Test Test Date Results
2 Step TB Skin Test - PPD
Chest X-ray (if TB is positive)
Rubella Titer MMR
Rubeola Titer MMR
Mumps Titer MMR
Varicella Titer Varivax
Hepatitis B Titer Booster
Hepatitis B Series
5-Panel Drug Screen
SLED Check
National Sex Oender Registry
Database Search, Check of the
Oce of Inspector General List
of Excluded individuals and
Entities ( LEIE ), Check of the
General Services Administration
( GSA ) list of excluded
individuals/entities, Federal
Criminal File Search, National
Criminal File Search
Clinician Signature Date
Clinician Name (Printed) Telephone Number
I understand that Tetanus and Diphtheria are serious, vaccine-preventable diseases. The CDC and the American College Health
Association strongly recommend that all college students be immunized against Tetanus and Diphtheria. However, I decline TD
immunization at this time. I understand that by declining this immunization, I may continue to be at risk of acquiring these diseases. If, in
the future, I want to be immunized with TD toxoid, I will be responsible for the cost of the immunization.
Student Signature Date
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis
virus (HB
V) infection. ( circle one below )
A. I have already received the hepatitis B Vaccine.
B. I decline the hepatitis B Vaccine.
C. If interested with the hepatitis B Vaccine, I contact my physician.
Continued on next page
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B
virus (HBV) infection. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk
of acquiring hepatitis B, a serious disease.
Should I become exposed to or contract any of the aforementioned diseases I agree to hold harmless the Facility, Faculty and Midlands
Technical College from any and all liability.
Student Signature Date
Applicants and students should be able to perform essential functions, or with reasonable accommodations (such as with the help of
compensatory techniques and/or assistive devices), be able to demonstrate ability to be proficient in these essential functions. Based on the
health assessment which you performed, please indicate whether you noted conditions which might limit the student’s ability to perform the
essential functions, or for which they will need reasonable accommodation to perform the functions:
Technical Standard Examples of
Necessary Activities
(Not all inclusive)
If yes, list the
Critical Thinking Critical thinking ability sucient
for clinical judgment
Identify cause-eect relationships in clinical
situations; evaluate patient or instrument
responses: synthesize data: draw sound
Interpersonal Interpersonal abilities sucient to
interact with individuals, families,
and groups from a variety of
social, emotional, cultural and
intellectual backgrounds.
Establish rapport with patients and
colleagues. Use therapeutic communication
(attending, clarifying, coaching, facilitating,
and teaching. Function (consult, negotiate,
share) as a part of a team.
Communication abilities sucient
for eective interaction with
others. in spoken and written
Explain treatment procedures; initiate health
teaching; document and interpret instructions.
Listen attentively.
Mobility Physical abilities sucient to
move from room to room and
maneuver in small spaces; full
range of motion; manual and
finger dexterity; and handeye
Move around in work area and treatment
Motor Skills Gross and fine motor skills
sucient to provide safe patient
care and operate equipment.
Use equipment and instruments with
necessary dexterity.
Hearing Ability Auditory ability sucient to
monitor and assess health needs.
Ability to hear alarms, emergency signals,
auscultatory sounds and cries for help.
Tactile Ability Tactile ability sucient for
physical assessment.
Perform palpation, functions of physical
examination and/or those related to
therapeutic intervention.
Olfactory Ability Olfactory senses (smell)sucient
for maintaining environmental
and patient safety.
Distinguish smells, which are contributory to
assessing and/or maintaining the patient’s
health status or environmental safety.
Attitude and
Ability to present professional
appearance and implement
measures to maintain one’s own
physical and mental health and
emotional stability.
Work under stressful conditions. Be exposed
to communicable diseases and contaminated
bodily fluids. React calmly in emergency
situations. Demonstrate flexibility. Show
concern for others.
Return completed form and all copies of requested documents to:
Corporate & Continuing Education
Midlands Technical College
PO Box 2408
Columbia, SC 29202